With many thanks to
All the amazing people at the Willow Bank Partnership Harriet, Ben and the team at live|work
Summary The NHS was formed to bring healthcare to every person in the UK regardless of financial or social situation. This simple idea has dramatically improved the health of the nation but has also come with a great financial cost, £108 billion per year in 2012. Since the beginning of the NHS, the service has proved to be extremely popular with demand constantly overwhelming supply. This has traditionally been met with increasing supply but with budgets reaching their limits the NHS must find ways to provide the same level of service for the same money. On the frontline, GP surgeries are struggling firsthand to deal with this high demand and believe a source of the pressure is misuse of services by patients, specifically making appointments for minor ailments which could be treated at home or by visiting the pharmacist. Health Portrait is a service design project that looked at the high demand situation faced by the GP surgeries and dove into the problem to understand patient needs and experience. At the same, it was important to understand how the modern surgery works and what it takes to run it. Insights were made after primary research, including interviews and shadowing. These insights led to the design of a new online service for GP practices to connect with their patients called Health Portrait. This service would be open between patients and professionals, allowing patients to share family, skills and information through a “portrait” with professionals. This “portrait” would provide a richer view of the patient allowing professionals to understand larger issues behind a minor ailment. The service would also provide a portal for patients to book consultations (online, email, phone and in person) through a system which suggests the appropriate professional for a person to see. Health Portrait aims to improve the relationship between patients and health professionals in the GP surgery while reducing the patient’s need for face to face consultations.
Contents List
Problem Introduction
Problem Introduction
Research
Health as a Concept The History of GP Services Demand Management of GPs Over-Usage of GP Services The Different Element of the NHS Stakeholder Map
5 6 9 10 11 12
Patient Lifecycles Patient Lifecycles Hotspots Shadowing GP Surgeries Shadowing Willow Bank Longton Shadowing Willow Bank Meir Findings from Shadowing Shadowing a Health Visitor
15 17 19 21 23 25 27
Navigating the NHS Personal Experience Interview with a Willow Bank Patient Interview Difficulties Personas Current Service Solutions
31 32 33 35 36 39
Background Information
Primary Research Behind the Reception Desk: The Surgery’s Perspective
Primary Research Sitting in the Waiting Room: The Patient Perspective
1
Insights
Insights
42
Concepts
Initial Idea Generation Short-Term Results Ideas Long-Term Results Ideas Selected Ideas for Development First Co-Design Session Leaflet and Token Concept Development Second Co-Design Session Patient Profile Concept Development Patient Profile Concept Testing Patient Profile Website Testing
47 48 51 52 53 54 55 56 57 59
Health Portrait Overview Storyboard Touchpoint Details Customer Service Journey Consultation Type Journey Map Emis Web Conclusion
63 65 69 77 79 80 81
Ideas, Design and Testing
Final Design Health Portrait
“Sometimes you can call at 10 minutes past 8am and the appointments have all gone... you can’t book ahead”
Problem from the Patient’s Perspective The waiting room, specifically the waiting part, is the problem because the doctor has taken on too many patients to try and meet the huge demand. But these people feel lucky to wait as they were one of the few that could get past the busy signal and get an appointments after winning the “lottery” of 8 am rush. At the same time these people had little selection on when to come in.
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problem introduction
“Urgent appointments that aren’t that urgent, over exaggerated complaints that don’t turn out to be that bad (flu, cold, rash)”
Problem from the Surgery’s Perspective The constant ringing phone is the problem. Receptionists have to sit on the phone for an hour straight in the morning dealing with the 8am rush and feel terrible turning patients down. Doctors and nurses have there time completely consumed and this leaves little time to get to know patients. Additionally, patients who are turned away may end up at the hospital for emergency care in order to be seen.
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Health Portrait is a project about the relationship between young families and GP practices. This relationship is the theme that runs throughout the entire project from initial problem, to research, to the final design solution. This project began in collaboration with live|work, a service design consultancy, who had been approached by Willow Bank Surgery group with a problem. The problem was simple on the surface, Willow Bank, a partnership of two GP surgeries, were seeing a very high and costly use of GP services and A&E, especially by families with young children, and needed to understand how to shift these patients into a more affordable model that is still satisfactory to their health and support needs. This was a problem for the surgery but they also understood that their patients were not happy with the current situation either. Patients have to call the surgery between 8 am and 9 am in order to get an appointment or there would be none available. If they were lucky enough to get through the constant busy signal they had very little choice on the time of the appointment. In addition, the Willow Bank Surgery would prefer to be spending time on community health prevention but the professional’s time is being consumed by the health needs of their patients. The root of the problem, in the opinion of the people at the surgery, are health issues being brought in that were not that servere. As one professional put it “Urgent appointments that aren’t that urgent”, over exaggerated complaints that don’t turn out to be that bad (flu, cold, rash). Through further research it was found that this problem is not exclusive to Willow Bank but found at surgeries across the UK. In fact, since the founding days of the british health care system there has always been very high demand for this free service from the public and it has always proved difficult for the government to budget in order meet this demand (Jones 78). Live|work is a service design consultancy based in the London with over 10 years experience having worked on a wide variety of projects ranging from private to public sector with clients including Orange, BBC, the NHS and many others. Live|work was approached by Willow Bank with their problem and I had the opportunity to come intern at live|work to take on this project. The area of public services and healthcare in particular always has been an interest of mine and I was grateful for the opportunity. Willow Bank Partnership is a social enterprise owned owned by the staff across the two surgeries in Stoke-on-Trent. Currently, they run the two GP surgeries with a patient base of 7000 people but would like to have more time to engage the public in proactive and preventative health issues. This project is an attempt to try something new at their surgeries in hopes of freeing time to achieve their wider social health goals.
problem introduction
Problem Introduction
Context Research
Background Information
Context Reserch
Health as a Concept In order to identify families health care needs and how these could be addressed it was important to understand the concept of health. The concept of health was explored as a base for this research in a general sense as it was not the major focus. The main question for this project was “What is health?” Through the research it was found that there are no right or wrong answers of what health is. It will vary from person to person and it is important to understand what health is to that people if you are looking to help them. Here are some definitions of health found: A state of complete physical, mental and social well being and not merely the absence of disease and infirmity (WHO 1946/84 cited Seedhouse 2001) Health and disease cannot be defined merely in terms of anatomical, physiological or mental attributes. the real measure is the ability of the individual to function in a manner acceptable to himself and to the group of which he/she is part (Dubos 1959 cited Seedhouse 2001) By health I mean the power to live a full, adult, living, breathing life, in close contact with what I love … I want to be all that I am capable of becoming (Mansfield 1997 cited Seedhouse 2001)
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As these definitions demonstrate good health can interpret a variety of ways, from the absence of any disease to the ability to live one’s life in an acceptable manner to them regardless of illness. As good health means different things to different people this has implications for health professionals and healthcare should work with the patient’s priorities and perceptions of health. Perceptions of health may be relative to age, life situation, life experiences, cultural influences etc. (Seedhouse 1998) Health care can also be viewed outside of the person. Health does not exist only in the individual: there are elements outside the individual which also make up health. They don’t just influence health, they are a part of health itself and they include aspects such as emotional, psychological, physical, sexual dimensions but also social, environmental, and spiritual dimensions. (Seedhouse 1998) Individuals put emphasis on different aspects according to personal priorities. For example: a sense of well being may be the most important factor of health for one person. All of this has an important impact on whether a parent decides to bring a child into to receive healthcare from the surgery. If the parent believes that any illness is bad health and that only doctors should treat bad health then they might overuse the surgery’s services. A person’s definition of health has impacts on how and when the access the services available to them needs to be considered.
Context Research
The History of the GP Services
As the tiling on the building shows, this hospital was supported by voluntary contributions from wealthy donators. These voluntary hospitals were the only source of professional health care for many of London’s citizens. Source: personal photo
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The Royal Waterloo Hospital was founded in 1812 and was one of two hospitals in London to care for women and children. It had just 80 beds. Source: personal photo
research
The general practice surgery is at the centre of the National Health Service, the NHS, in the UK. The government has shaped the GP surgery’s role in the health care system to be the primary supplier of healthcare and the main source to shape people use of the NHS. This position is unique in the NHS and comes as a result of the General Practitioner’s long tradition and place in society. Society has had people providing medical treatments for thousands of years but the GP, as we know it today, has its roots in the 1800’s.(Jones 68) If you were born 150 years ago in the UK, your relationship with the doctor or GP would depend a great deal on a variety of factors. The main factor influencing whether or not you saw a doctor for a medical problem was money. GPs were like any other profession, such as lawyers or accountants, and in order to access their services you had to pay. Since doctors ran their practices like businesses it made sense for them to set up their practices in wealthy neighbourhoods where more clients could afford their services.(Timmins 89) This lead to location, the other main factor which affected one’s access to a GP. There might not be a doctor in the neighbourhood were a common worker in a larger city or town would live but these people could access one more easily than people in the country could. Medical access in the countryside, especially the poorer areas, was almost impossible and required traveling great distances. However, at this time there were other healthcare professionals available to people with less money. Midwives were commonly available for the difficult job of delivering babies and their specialized skills in this area meant a person would be in relatively good hands. At the same time, voluntary hospitals started opening to care for those people who could not afford to pay for medical treatment. These hospitals mainly cared for the poor who had sustained injuries and could return to work if treated, excluding women, children, and disabled people. (Timmins 96)
The turn of the century saw the conditions improve slightly as better paying jobs saw more people being able to afford some primary care but it was still far from the majority. In 1911 the government realized the importance of keeping its workforce healthy and created the National Insurance Act. This act required workers to pay a portion of their salary into a fund in exchange for access to GPs and hospitals. This act excluded their spouses and children. As the decades progressed calls were made to make this scheme available for all and free of charge. (Jones 123) The voluntary hospitals supported this plan as they were finding it increasingly difficult to gather donations to keep up with the increasing costs of caring for the sick. On the other hand, the GP’s resisted this movement vigorously as they did not want to become civil servant and wanted to maintain their independence. (Timmins 99) After World War 2 the nation was feeling great unity and camaraderie and the GPs were on the wrong side of public opinion. Building upon the 1942 Beveridge report, which identified a health service as one of five “giants” of a social security system, Aneurin Bevan brought the National Health Service Act (1946) to government and it was passed, thus starting the NHS. In order to get the GPs support he allowed them to operate as independent contractors rather than salaried government workers, a condition which exists to this day. The NHS was set up as a universal health care system which is free of charge at point of use and available to every citizen in the country. The GPs were designed to the be the ‘gatekeepers’ to other services in the service such as the hospital thus people were required to register at a GP to access the NHS. The new service was a huge success and 90% of the population was registered at a GP within a month of starting. (Jones 133) The NHS has continued to evolve through the years most significantly during the early 1970’s and the 1980’s under Thatcher. This service has made significant advances in the health of the nation. The diagrams on the next page show life expectancy has increased by 15 years for the average UK citizen and infant mortality has declined by 85%. (DOH 2009) However, these changes have come at a financial cost as the next diagram shows the cost to run the NHS has increased by 100 billion per year after being adjusted for inflation.
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“There is a sheer increase due to people getting things they need but could not afford before.” (Public Records Office, 1948 cited Jones 2008)
This huge increase in cost has been a constant struggle for the NHS since its inception. In the first year of operation the budget had to be doubled as demand was higher than expected. It was thought that once an initial rush of patients had been treated for existing untreated conditions the demand would fall but it never did and has actually increased ever since.(Jones 161) This problem which has existed since day one of the NHS is what this project investigated. How can you manage demand for a free service which is very popular? Currently, the NHS is the fifth largest employer in the world with 1.8 million employees and is the oldest, largest public health service in the world. However, it is undergoing massive changes as it looks to serve the existing
population with less resources. The budget has been frozen five years since 2011 effectively meaning it must find £20 billion in savings over that time to continue to operate.(Butler 2012) This has led to changes in the way the whole service is going to be structured and run. However, at its core it still has the same problem since it began which is an issue of public demand. This project is an optimistic one. It looks at a system, formed from an idea that healthcare should be accessible for everyone regardless of financial situation but is currently under great strain and says “this can and must work”.
The NHS has improved the lives of millions of people. The health advances have brought more people into this world and extended the lives of many others. Source: Department of Health (2009)
Life Expectancy in UK Male
Female
1948: 60 years Today: 75 years
1948: 65 years Today: 80 years
Infant Mortality in UK (Deaths per 1,000 live births)
1948: 34
Today: 5
Health Care Budget in UK (Adjusted for inflation)
Today: £106 Billion
research
1948: £9 Billion
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However, during this same time the cost of running the NHS has increase dramatically. These budgets may have reached their peak and now the NHS must increase services without increasing spending. Source: Department of Health (2009)
Context Research
Demand Management by GPs The problem of high demand for the services provided by the GP surgery have led to a number of strategies and attempts to deal with the issue. Some techniques, such as the appointment system, have evolved over time and different surgeries do these in their own unique way. Other ideas have centred around a marketing strategy to help educated the patients about effective use.
Appointment Systems The early appointment systems in the 1800’s for the more wealthy patients required someone from the household to call for the GP when needed and the GP would visit the house of the patient the majority of the time. With the start of the NHS it became inefficient for the GP to visit the long list of patients and patients were mostly required to come to the office.(Jones 111) Most acute illness was dealt with on a first come, first served basis and resulted in long waits. As the telephone became more pervasive GP surgeries began taking advanced bookings over the telephone. However this created its own issues as now it is not uncommon for every appointment to be gone within an hour of a surgery opening.(Martin, Dunbar-Rees 2012) Some practices have begun taking bookings over the internet but only for advanced booking for non-urgent reasons.
Additional Help Nurses have long been a part of the health care system and their role in whole NHS has been constantantly increasing. This is mainly due to it being cost effective to have nurses helping doctors with certain tasks thus allowing more patients to be seen. The nurses role in the GP surgery has grown significantly over the years with many roles being created such as: Nurse Practitioner, Practice Nurse, and Health Care Support Worker. These different levels can take care of a wide variety of issues, by some estimate up to 70% of all cases in a GP surgery. (Seedhouse 2001) However, these nurses are not well understood by patients and can cause confusion. This will be explored further in a later chapter.
The first come, first serve wating room is an primative demand management. Source: nhs.co.uk
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Self-Care Promotion The therory of self-care proposes that if patients had more ability to look after themselves during routine illnesses, such as coughs and colds, then the GP would have more time to care for more serious illnesses. Self care can have limited effect though, one study in 1967 half the patients in one practice who were given a self care book. About 60% of people felt that the book made them more able to deal with a problem themselves. However, the consultations rates for those who read the book and those who did not were nearly identical.(Platts, Mitton, Boniface et al. 2005) This study showed that promotion and education may have limited effect on patient’s use of health care services. These are a few of the major efforts to deal with the demand of patients either through prevention or management. It is not a complete list, but gives a glimpse into kinds of efforts that have been made and what can be learned.
Nurses have played an important role to increase the capacity for patients in GP practices. Source: nhs.co.uk
Context Research
Over-Usage of GP Services The problem of patient misuse of services isn’t limited to Willow Bank, it is also occurring across the country. A recent IMS Health study was conducted that looked at the GP appointment data for issues that could be resolved at home. These statistics show this is a national issue and represents at least 2% of NHS spending (Tisman 2008)
51 MILLION which works out to ...
18%
which works out to ...
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common reasons for appointments...
(Tisman 2008)
Context Research
The Different Elements of the NHS The NHS is an extremely large and complex organization. In order to understand the role of the GP it is important to have a little overview of the different levels of services provided in the system. These are important to understand as people have options when deciding on the healthcare they wish to receive and those decisions have consequences which will be expanded upon in a later section. Below are the major services: Hospital As a patient you can’t just access the services of the hospital. You must either be referred by another professional for a reason or you may be admitted after being treated at the Accident & Emergency (A&E). The hospital handles the most serious and urgent cases. Accident & Emergency The A&E is a part of some hospitals and is designed to handle patients with urgent issues that may result in serious conditions or death. However, people tend to overuse this service with non-serious issues due to the 24 hour availability of the service and the fact that all patients there will be seen by a doctor. Urgent Care Centres Similar to A&E these centres are meant to handle urgent case but those that will not result in death, such as broken bones, cuts, and injuries. There are not many of these centres and they are not well known. Out of Hours Clinics and Walk In Clinics These clinics are meant to handle patients with illnesses that require the attention of a GP but operate at late night or when their GP surgery is out of appointments. These facilities are relatively new to improve the burden on the A&E and people have yet to become accustomed to them.
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GP Surgery A great deal has be said about surgeries already but in short they are meant to be the gatekeepers to the NHS system. A patient is required to attend before seeking specialist services or hospital care. The GP surgery also has computer data on the usage and conditions of its patients allowing management of the patients usage. Specialists There are a wide variety of specialist available to look at every aspect of the human body. Generally a referral is needed for these specialist in order to ensure that they see only the patient who need the services. All of the services described above have a few more sub-options resulting in dozens of types of health professionals that a patient can see. This has its advantages in allowing for very specialized work to be done in a cost effective way but it also can be challenging for people, including NHS staff, to navigate.
Context Research
Stakeholder Map
health visitors sure start centres
community patients business managers
general practitioners
nursery
school nurses
receptionists nurses primary
support groups
NHS
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secondary
Primary Research
Behind the Reception Desk: The Surgery’s Perspective
Primary Research
Patient Lifecycles General Young Family Cycle
Confirm
Check Ups
Prepare
Birth
First 8 Weeks
Check at Home Test at GP Surgery Entered into system
Get due date Scan at 12 weeks Scan at 20 weeks
Education on birth Parenting advice
Baby is born Usually at hospital
Checks at 10 days and 8 weeks
GP
Hospital
MIdwife
Hospital / Midwife
Health Visitor
GP Relationship Cycle
Selection
Register
New Case
2nd Consult
Find GPs in area Assess Options Choose GP
Go to office Fill out paperwork Submit
Make appointment Travel Wait Evaluate Treatment
Make Appointment Travel Wait Evaluate Adjust
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GP Visit Cycle
Evaluate
Decide
Prepare
Evaluate Inform
Check Information Make Appointment Plan
Prepare Child Get Docs Travel
Second Year
School
Second Child
Check at 2 1/2 years
Checks starting at 5
Pregnancy Birth Checks
Health Visitor
Health Visitor
Health Visitor
School Nurse
Ongoing Consult
Resolution
Referral
Disagreement
Check Appointment Travel Wait Evaluate Adjust
Illness is resolved Stop going to GP
Evaluate Referral Guidance
Check other sources Raise with doctor Evaluation Treatment
GP Office
After Visit
Follow Up Visit
Tell Reception Wait Describe Symptoms Evaluation Discuss Advice
Pharmacy Treatment Reflect Criticize
Discuss Evaluate Adjust
Patient lifecycles were produced in order to understand where to focus when researching and interviewing patients. These lifecycles were developed based on initial conversations with parents to identify the key stages and steps at each level.
primary research
First Year Check at 1 year
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First 6 Months Check at 6 months
Primary Research
Patient Lifecycle Hot Spots The lifecycle was printed out on sticky notes, to allow rearrangement, and brought to Willow Bank Surgery in Stoke-on-Trent. A brainstorming session was held working with some of the staff to identify key stages in a young family’s lifecycle along with problem areas in the general appointment service journey. Interesting points were raised regarding the relationship cycle which fits between the two. Additional issues that didn’t fit on the lifecycles but needed further exploration were written on sticky notes and added to the wall.
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Hot spots were identified with sticky tags. Visually it became easy to see areas of interest to explore. Source: Personal Photo
Working with staff was useful as it allowed for areas of interest to come to surface quickly. Source: Personal Photo
First 8 weeks of child’s life is a very high use period 50% of children do not come in for vaccines at first Between the 1st and 2nd year is an interesting time Health Visitor and GP only interact over problems Second child usually means double the appointments Why do people register with Willow Bank? There is a New Patient introduction to register patients Long term conditions have big effect on usage What are people’s skill set? What are people’s social health care support? Making appointments is filled with difficulty No options for people who get sick in the afternoon Booking follow-up appointments can be confusing
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• • • • • • • • • • • • •
primary research
Important Stages and Steps to Investigate
Primary Research
Shadowing GP Surgeries Two days were spent shadowing the two Willow Bank surgeries in order to understand how service works and the challenges they face. The two surgeries are located in Longton and Meir which are boroughs of Stoke-on-Trent. Although they are roughly 2 miles apart they have dramatically different client bases and challenges. It was extremely interesting spending time with the staff and seeing the difficulties that they face. A great deal was learned during this time but another week could have been spent in the practices learning all the details. The interaction and requests from patients can be extremely complex with needs far beyond what the practices can offer.
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Willow Bank History
2004
The PCT (local health authority) decides there is a need for a new GP practice in Longton and opens the practice itself. The PCT hires the doctors and runs the practice on its own.
2005
After running the Longton branch for over a year, the PCT decides they shouldn’t be running the GP practices and puts the practice up for tender.
2006
A small group of people working at Longton form a Community Interest Group to run Longton. The social enterprise wins the tender and Willow Bank Longton is formed.
2008
The PCT decides there is a need for new GP practice in Meir and puts out a tender for the practice. Willow Bank bids for it and wins, setting up the new practice in portable buildings.
2011
Willow Bank Meir moves into a brand new building which is a health centre with other health care services in it, such as blood work.
Willow Bank Longton Overview • 8:30 - 17:00 Monday to Friday • Set up inside old garage • Day-of appointments filled by 12pm
Patients • • • •
3000 Patients Mainly South Asian Some Czech Practice has built up trust overtime
Issues • Fever can mean death in previous countries • Belief that british health care can fix all • Friday afternoon busiest (weekend closed)
Willow Bank Meir Overview • 8:00 - 20:00 Monday to Saturday • New shared building • Day-of appointments filled by 9am
Patients
Issues • Parents are overly nervous • Issues of state dependance • Monday morning busiest
primary research
4000 Patients Mainly lower income white British people Some drug users More young parents
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• • • •
Primary Research
Shadowing Willow Bank Longton Willow Bank Longton’s building is an old automotive garage which makes it quite dark inside. The location is not very accessible by public transit and most patients walk or drive to the surgery.
The waiting room is tidy with lots of chairs. There are a fair amount of posters on the wall which make the room feel somewhat cluttered but that is not unusual for NHS surgeries.
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The reception area is directly connected to the room and all three receptionist are able to see who is standing at the desk. This allows for some continuity for patients and reception staff.
One of the receptionists at Longton is a Carer for her mother and learned about a number of NHS programs for Carers from working at Willow Bank. In order to help other Carers learn about these programs the receptionist created these badges that the staff wears.
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Like most GPs, Willow Bank runs a Patient Participation Group to get input from their patients on what to improve. One obivious example was there was no sign outside Willow Bank and the surgery was always looking for new patients. The patients suggested this would be an obivious form of advertising and help people find the location.
primary research
These appointment cards are given out to patients. Willow Bank has a system were if a patient misses 3 appointments they recieve a warning letter from the management. Willow Bank also has the right to “fire� a patient. However, missed appointments are not common with an estimated 3 or 4 a week.
Primary Research
Shadowing Willow Bank Meir Willow Bank Meir has a brand new building which they share with a couple of other GP practices and other health services. The accessiblity is simlar to Longton with one bus so most patients drive or walk.
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The waiting room is bright with lots of space and plenty of seating. The posters are restricted to one board and leave the space feeling clean.
The reception area is split between the front and the back. Only one receptionist is up front and it is not the same receptionist that books in appointments in the morning. Additionally, the patients check in with a machine meaning there is very little continuity for patients.
Patient check in for their appointment at touch screen next to reception. Most people seemed to navigate the screens quite well but there was some difficulty. The screens mean some people rarely have face to face contact with the receptionists.
The reception has this cheat sheet to help understand the different professional and the illnesses they handle at the practice. The roles of the professionals are complicated and its difficult to understand. Also, this cheat sheet barely helps as it is filled with technical terms and shows the doctor only treating 4 conditions while the nurse can do dozens.
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Screens let patients know what rooms they should go to in order to see the doctor. In between patients the screen show health tips and advice.
Primary Research
Findings from Shadowing The key findings from the 2 days at Willow Bank are shown here. The major insight was that Willow Bank is a very complex and busy place. Everyday close to a dozen people handle around 70 appointments with patients, dozens of prescriptions, follow ups with hospitals, booking of appointments and a small mountain of paperwork. Another observation is that peoples health needs are quite numerous and complex with hundreds of different codes to register peoples conditions. Finally, the practice has evolved to spread this workload but this design has led to a complexity that receptionist and patients can find difficult to navigate and default to their habits of previous experiences.
The Pyramid of Care This was one of the most important findings from the trip to Willow Bank. It is a diagram that was drawn first by a Nurse Practitioner that shows the 5 different levels of professionals available at Willow Bank. It is arranged like a pyramid because at the bottom is the person with the widest experience and training, the GP, and at the top is the person with the narrowest training, Health Care Support Worker. This shows that there is far more than just a GP at the GP surgery and each professional has their own area of expertise.
lower level of training and experience
Care Support Worker
Clinic Room Nurse
Practice Nurse
Nurse Practitioner higher level of training and experience
General Practitioner
Patients Perception The GP surgery has undergone great efforts to have a variety of people to share the workload. However, the patient perceives the GP surgery to be mainly a visit to the GP and nurses are a lesser option for most. In reality each of the professionals have their own roles and it is important to spread the workload efficiently and effectively.
GP
GP
nurses
clinic nurse
practice care support nurse worker practitioner nurse
patients perception
practice reality
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Responsiblity for Navigation These different levels of care for different ailments can make it quite complicated to determine what patient should see what professional. Patients have little education on the suitability of different options. Reception staff have no training and must learn on the job which professional should handle different conditions. There is a disconnect between the front responsibility for bookings and back end knowledge of the appropriate professionals.
receptionists knowledge of different levels of care available
patients low
responsiblity for booking high appointments for care front end
GPs
nurses
knowledge of different levels of care available
managers high
responsiblity for booking low appointments for care back end
Appointment Types per Session Appointments are broken down into 3 rough categories. There are advanced booking which patients can request for non-urgent things such as check ups or help to quit smoking. Then there are the same day appointments which are for more urgent matters, mainly acute illnesses. The same day appointment are locked until 8am when the open for reception to book them. Finally, one appointment is saved for an urgent patient who might phone in the afternoon. This urgent spot is usually saved for a child.
3 appointments for advanced booking
12 same day appointments unlock at 8:30 am on day (Doctor can request for spots to be unlocked)
1 urgent end of day saved
Advanced Appointment Availablity Earliest at
Longton Earliest at
Meir (any doctor) Earliest at
Meir (Dr Gregon) Advanced at
Appointments can be booked 4 weeks ahead 1 week
2 weeks
Same Day Appointments Offered
4 weeks
8:00 am
General Practitioner
General Practitioner Nurse Practitioner Phone Triage Nurse Practitioner 9:30 am
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Not all appointments are the same as previously mentioned. There are up to 7 different kinds of appointments available to patients. Starting at 8 am phone rang for close to 1 hour straight. The GP spots filled quickly and the receptionist had to resort to other options to try and meet demand. Spots with the nurse practitioner were offered and the phase “Is it something the Nurse Practitioner can help you with?” was used. This phrase didn’t put the patient on the spot or dig into their private life and was well received.
3 weeks
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The advanced appointments are available up to 4 weeks ahead of time. However, there is great variety between when the earliest appointment is available. As the charts shows, at Longton you can see a doctor within a couple of days. However, if you want to see Dr. Gregon at Meir you could have to wait a couple of weeks.
Primary Research
Shadowing a Health Visitor A day was spent with Lynn, a health visitor in Meir, Stoke-on-Trent in order to understand other perspectives in family health care. A health visitor is responsible for the monitoring of the development of the new born babies in their area and visits with the children at age milestones. Typical visits occur a couple weeks after birth, 6 months, 1 year and 2 years. After this the child’s development is shifted to the school nurse. I went on two house visits with Lynn as she met with families. The major takeaway from these visits was that the health visitor is responsible for the full development of the child not just the health aspect as with the GP. This means check for physical development, mental development and ensuring that the environment they are being raised in is acceptable. Lynn said she wants to ensure that these children have the opportunity to reach their full potential. The most interesting part of this was the gentle way Lynn would check on the environment the child is being raised in. A question she always asks is “Who is living in the home with you?�. She explained that if the home environment is stable over time it is a good sign of positive parenting. Lynn would also ask about the other children and check on how they are doing. She later explained that every question helps you paint a picture of that person and determine if that person needs more attention. All this information means Lynn knows these families extremely well and this knowledge helps her do her job of ensuring these children have the most opportunity available to them.
health
27
primary research
health visitors
environment
development
The health visitor is responsible for the full development of the child. This includes health, mental development and the environment they are raised in.
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primary research
Primary Research
Navigating the NHS
31
primary research
An important issue that came forward from talking with people and researching the NHS, it was simply, “Where do you go when you get sick?”. This straightforward question was actually anything but simple. As explained in the context section there are at least 6 different places people can go to for help and then further options inside each of those. Most people talked to have their own way of dealing with being sick and there was no universal system. Some would wait any illness for three days but after that an appointment would be made. Other would get appointments quickly as they don’t have time to be sick. Still other would resist the doctor completely. And this was just for a cold or flu. When things become more complicated it becomes difficult to determine what would should be seen at the A&E and what could go to pharmacist. For example, NHS has a game to play to see what service a patient should go to. One question was about difficulty breathing during the day. I picked the GP in a couple days and the correct answer was the A&E. Something I perceived to be harmless could be very serious. (www.miltonkeynesccg.nhs.uk/ choosewellgame/) To deal with this there has been a few attempts to help people through this process. Below are a couple of examples. For both it is actually quite difficult to judge the effectiveness because of the variability of the each case but they are interesting to review.
Choose Well is a campaign to communicate the different levels of care using a graphical treatment. The campaign has been well received in the for its graphic design but the effect on the public is unknown currently. Source: choosewell.org.uk
NHS Direct is 24 hour phone line and website that provides health advice and reassurance. Users have the opportunity to talk to nurses for health advice and navigation. However, the effectiveness has been questioned and recently reduced its staff numbers by 50% Source: nhs.co.uk
Primary Research
Personal Experience
32
I joined my local surgery to go through the process of registration. My NHS card came with this letter explaining the different services available and when to use the services. The information was useful but I failed to notice it upon receiving the letter. Source: nhs.co.uk
primary research
In order to understand the NHS better I signed up at my local GP surgery. This helped me see the experience through the patients eyes and to relate to certain aspects they are talking about. I started by searching on NHS Choices, this is a website which lets you see the practices around you and provides reviews from other patients to help you decide. I picked one based on proximity and generally favorable reviews from other patients. After picking, I walked to the surgery and asked to register. The receptionist handed me a sheet to fill out and sent me to the waiting room to fill it out. The room was quite dark and filled with posters and leaflets. The form was easy to fill out and asked standard questions along with my medical history. After handing in the form, I asked about the appointment system. The receptionist explained that I would have to phone in the morning for an urgent problem and I could call ahead for advanced appointments. They gave me a card with basic information about the practice like opening hours. After a month I received my NHS card which let me access other services. Along with the card came a letter which explained the different services provided by the NHS and when to use them. Overall the experience was good but there was certainly room for improvement, especially introducing the services provided by the surgery along with basic information.
Primary Research
Interview with Willow Bank Patient
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primary research
• • • • • • • •
Interview with Steph, 25 Lives with husband, 29 They have two children Karen is two and half Samuel is 18 months Registered early 2011 Vaccinations up to date Medium users
An interview was conducted with Steph, a Willow Bank patient, in order to get the patient viewpoint of the services along with their health care usage. The interview was very interesting and provided real insights into what its like to care for children’s health as well as adults. The interview followed a guide which can be found in the appendix and lasted approximately an hour and a half. Conducting the interview was the business manager at Willow Bank and myself. Steph and her family have recently moved to Stoke after life on an army base in Germany. Her past experiences on the army base and from her childhood upbringing form the bases for her health knowledge, which she feels quite confident about. She will usually wait out any illness for 24 hours as she doesn’t want to “waste people’s time”, including her own and uses old wives tales to treat issues. However, once she has (self ) diagnosed the problem and has decided it needs addressing she “keeps on and on to get the outcome you want”. She has a distrust of the doctors and likes it when they “tell it how it is” Sonya visits Willow Bank most as it is the closest and only resorts to the walk-in clinic if she can’t get an appointment at Willow Bank. She lacks information about the appointment booking system and has never been offered an advanced appointment, even though most of her personal appointments are non-urgent and preventative. Karen has been seeing an Outreach Worker for speech and behavioural issues and Steph really appreciates the support, “She’s been a lifesaver”. It is a part of a Positive Parenting Programme. Steph is seen by her friends as a health “resource” and receives texts from her friends asking about their children’s health. In conclusion, Karen is a confident user of health services and tends to diagnose the problem herself and views the GP as a gatekeeper to the treatment she wants. This interview was the major source for one of the personas shown.
“Doctors get sick of me, believe me... you have to keep on and on and on and on and then you get the outcome that you want. I eventually get, not so much get my own way, but the outcome that I wanted to”
“Sometimes you can be 10 minutes past 8 am and they (appointments) have all gone... you can’t book ahead, I’ve never been able to book ahead.” “I think I just picked it (health knowledge) up from my Gran to be honest, old wives tales. I think thats how her mother did it.” “A few times we have debated bringing my youngest to A&E but we decided we will phone the doctors tomorrow because its not really, really bad and we don’t want to waste peoples time... in the end we ended up going to the Walk In Clinic in Hanley because we couldn’t get the appointment”
“I only go to the doctors when I know what I want. There is no point in going otherwise or you’re just wasting peoples time.”
“My friend always text with photo’s of whatever’s wrong with their kids.”
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“They say “sorry we don’t have appointments with the doctor can you take the nurse.” I’ll have to won’t I”
primary research
“If you phone up at 8 o’clock they don’t have appointments till 11 or 12 o’clock and it’s like “eh?”, I phoned dead-on 8 o’clock so I should get it around that time”
Primary Research
Interview Difficulties
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primary research
The one interview was very insightful for the development of the project and it was planned to have at least 4 in order to get a balanced view perspectives. However, this proved to more difficult than predicted as patients didn’t answer phones and a couple patients that did accept an interview backed out at the last minute. It was felt that a cash incentive would have increased the number of uptakes but the surgery was not comfortable with this and time ran out. This was a disappointment as a lot of time was spent designing the interview and paper based task which are seen below. The interview was done in three main sections which were: • What is your relationship with Willow Bank? • How do you decide you need some medical assistance? • Where do you go when you decide you need that assistance? These questions would have helped to understand the patients thought process before, during and after a service encounter with the GP surgery. The lack of interviews did provide some insights though. First, it was interesting that people demanded a great deal from the surgery but when the surgery ask for something the patients were not willing to share. It shows a patient belief that the practice being something to be used and not a mutual relationship. At the same time, the view into the patient’s life was very interesting for everyone at the practice and a question was raised “what if the practice could know this much about every patient?
An interview guide was designed to be used for the meetings with patients. It included a discussion guide along with paper based tasks: “Your Family Health History”, “Your Health support resources” and “Your last visit to... “ see the appendix for copies of these.
Primary Research
Personas Personas were developed based on the interview along with interesting stories about patients lives learned from time with the health visitor. These pesonas help paint a picture of the different reasons people might be coming into the practice. It became clear from just a few stories people usage has more to do with their beliefs and personal situation rather than any physical problem.
The Self-Confident Parent • young mother with working husband • high self-confidence • low stress
Background Story Poor past experiences have eroded her confidence in health care professionals. She feels her life experience to this point has given her enough health knowledge to handle certain conditions. Sometimes this results in repeat visits with health care professionals in order to get the outcomes she desires.
Example
36
primary research
Her son has a cough which rattles when she listens. She has decided this is an infection and only will clear with the use of antibiotics and books an urgent appointment with the GP. Current health thinking is that the use of antibiotics should be avoided if possible however the GP doesn’t communicate this to her and sends her away without alternative treatment. Unsatisfied, she returns 3 more times to until she gets the drugs she believes will remedy the situation. Feeling vindicated, her confidence in professionals is further eroded.
The Dependant Parent • young single mother • low self-confidence • medium stress
Background Story The dependant parent had a difficult childhood. Going to public school with dyslexia has destroyed her self-confidence as she routinely failed tests and was mocked by her classmates. She doesn’t believe she is capable of handling any challenge put her way.
Example
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primary research
Our parent wakes in the morning to find her 2 year old is not feeling well and is warm to touch. Unsure of what to do she phones the practice to book an urgent appointment, knowing if she doesn’t exaggerate she won’t get an appointment. Upon seeing the GP, she is given a diagnosis of the flu and is given instructions to hydrate and monitor temperature. Later that night her child wakes from the fever and is unwell but generally alert. Having no faith in her ability to handle the situation she goes to straight to the A&E as it is the only service she knows that is open at this time. The doctor at the A&E sees the child and give her the same instructions within 18 hours of seeing GP.
The Anxious Parent • young father with working wife • rattled self-confidence • high stress
Background Story The anxious parent has had his life turned upside down by a layoff 8 months ago from his job of 9 years. Future economic uncertainty has made him unsure of everything as his life decisions up to this point are now in question. How can he trust himself with the lives of his children?
Example of Appointment Making
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primary research
While spending the morning at the park with his children he notices his son has rash on his arm. He takes a look thinks it is probably nothing and they continue with their day. By the afternoon he has checked it many times and it doesn’t seem to be going away. He goes to the internet to look for reassurance but instead the opposite happens. He calls the surgery demanding an emergency appointment as he is convinced it is meningitis. The surgery makes room for the child and squeezes him in at the end of the day only to determine it is a simple reaction to a plant in the park.
Primary Research
Current Service Solutions Here is some examples of other services or parts of services which were researched. The examples provided insights into the range of options and techinques being used both in the private and the public sectors.
Sherpa
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primary research
This service is based in New York City and acknowledges the health care system is complicated to navigate. As a member of their service, you call them first when you have a health care issue and they guide you to correct level of care, saving you time. They can also get users to do steps before a trip to the doctor, such as blood work, to save steps in the journey. Healthcare is private in the USA so cost efficiency is at play here for the service provider.
Sky Customer Service Similar to the GP practice, customer service centres can get huge volumes of phones calls for information available on the website already. To try and reduce the calls, the website asks you to put in the reason for your call before they give you the phone number. Once you enter the reason, links to articles which may help your situation are displayed. This may let some users solve the issue on their own.
care 4 care This service allows people to bank time they spend helping elderly people and use that time to receive care when they are older. The service allows elderly peoples needs to be met outside the traditional model of public care. The function of this service does not inform this project directly but the idea that needs can be met outside the traditional setting is useful.
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This text message service sends new mothers a text message every week from the day their child is born. It gives timely advice on the stages of a child development and signs to look out for. It also gives advice on the mothers health care preventing complications which could then impact the babies care.
primary research
NHS Parents
Research
Insights
Evaluate
Appointment
Arrive at GP
Check In
Patients and reception staff have difficulty navigating the many levels of nurses and GPs.
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insights
Supporting Evidence: Shadowing the surgery and talking with patients led to this insight. Talking with reception staff it became clear that they recieve no training on what each professional can handle.
Patients varying histories and situations affect their usage of services provided by the surgery.
Appointments are percieved to be most valuable when with the GP, nurses are seen as secondary.
Supporting Evidence: Patient interview and talking with the health visitor provided this insight. In particular, the health visitor knew a great deal about the patients in the area and the issues affecting them.
Supporting Evidence: This insight was first considered after talking with reception and confirmed from talking with patients. Patients had little knowledge about the ablities of the nurses and nurse practitioners.
Review History
Symptoms
Action
Self Care
The time presure on appointments makes it difficult for professionals learn about patients background. Supporting Evidence: Appointments are 10 minutes and there is constant pressure to be quicker. This leaves little time to discuss anything outside the reason specifically mentioned regardless of best intentions.
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Supporting Evidence: Patients expressed difficulty remembering diagnosis and treatment advice after leaving the office. Professionals will print out information for some patients but no patient accessible record is available.
insights
It is difficult to deliver treatment advice and prevention information to patients.
Concepts
Initial Idea Generation The insights from the conclusion of the research phase generated plenty of inspiration for ideas. There was enough of concrete information in order to improve small aspects of the service on a day to day basis with “quick fixes�. There was less evidence, due to the lack of interviews, to support larger, long term ideas which would really change the levels of demand so it was decided to work with what was available and test ideas in the practice. The ideas were also ran against a framework to see if they were managing the demand or reducing it. 1. Manage the demand Improve the way in which demand for services is managed through improved systems and/or better understanding of the systems by staff or by patients. 2. Reduce the Demand Design ways to reduce the need for families to want the doctor appointment as their first port of call when they have a medical issue.
47
conepts
These distinctions were useful in understanding the potential of the idea as in the end it was much more desirable to reduce the demand rather than manage it. The ideas came from everyone who was involved in the project and went through some quick development before being drawn up and present back to the surgery to get feedback on the feasibility and the possible impact. As mentioned, different ideas were clustered into short term results and longer term results solutions. Generally short term results ideas were quicker to develop and test but generally managed demand rather than reduce it. Longer term ideas required more time to see the effect and required more development to test. The hope was that these ideas could be tested in Willow Bank surgeries and the effectiveness could be validated before major investments. There was great value in working with the surgery to see which ideas could work as they know what has been tried before and what could make a real impact to the problem they were seeing. This also allowed for aspects of one idea to be blended with another which was interesting process to be apart of.
Concepts
Short-Term Results Ideas Referral Card A referral card to help the receptionists know when a doctor has requested a follow up and when it should be scheduled. One of the receptionist mentioned that one of doctors used to do this but has stopped. She found it very useful to have the confirmation as she doesn’t want to confront patients over this. Could be a printed card that is filled in or a token system that could be reused, saving paper and printing costs.
Come back
Dr. Be to: nson In a coup le
days In a week In a mon th
Sell the Nurse Practitioners Promote the advantages of the Nurse Practitioners, such as extra time and prescriptions, not just what ailments they can treat. Meet our Nurse Practitioners
Currently the NPs are viewed as a last resort by patients but NPs are able (and extremely willing) to handle a wide variety of issues. They also have more time for the patients, can prescribe, help patients with education and have quick access to the doctors. Patients are currently unaware of these services which could free up doctors time.
They have to offer:
More Time
Prescriptions
Education
Book with them for: Colds Flu Rashes Bumps and Bruises
Review Appointment Order Nurse second...
Doctor third.
concepts
Currently, the first patients are given doctors appointments without question. Once doctors appointments are gone the patients are offered nurses and finally callbacks from a doctor. These are not being given out in a way that matches patient needs.
Call back first...
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Offer more than just a doctors appointment to the first people that get through on phone in the morning.
Texts/e-mails to GP for advice Providing patients with a way to access a doctor using alternative ways such as texting and emails. Using these technologies would allow the use of photos and video to be added thus providing additional diagnosis information. Doctor could decide if and when an appointment would be necessary.
Doctor. I have a rash I’m concerned about. Can you take a look? Sure! Send a picture over so I can get an idea. Thanks.
New Patient Check - “What We Offer” An explanation of the the services offered by Willow Bank and how to book them during the new patient check. What Willow Bank Offers
New patients checks are great time to introduce the different levels of health care available at Willow Bank and how to book appointments for them. The “Nurse Pyramid” was shown to us by one of Nurse Practitioners and it was helpful to visually understand the different levels of care provided. Something similar could be designed for a leaflet.
Reception to be “Health Navigators”
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concepts
Reception trained to help navigate patients through making the right choice of Willow Bank’s services, and even for the NHS at large. Reception currently gets no medical training whatsoever and has to learn on the job about different medical conditions and who treats them. It is the first point of contact for patients and if reception understood more about the services offered they could help patient get the correct treatment.
Different services to keep you healthy 1. Health Care Support for ongoing 2. Nurses for blood work and checks 3. Nurse Practitioners for minor illness 4. GP for major or complicated illness
Nurse Practitioner for New Mums Each family would be assigned to a Nurse Practitioner and they would be able to contact the nurse directly if they had any questions. This would give parents direct contact with a consistent professional that could help assess and guide them through health care situations. This would start with pregnancy so a relationship would be in place when the child is born.
Specialized teams for patient groups Teams made up of staff from different roles would work together each focusing on a specific patient group. These teams would focus on a specific target, such as families, to learn about the patients in this group and their needs. Then they could come up with ideas on how to better serve these patients.
OAP Team
Family Team
Frequent Flyer Team
Scripts for Follow Up Appointments
concepts
Some patients get confused on whether to come back after a check and this could help clear things up while reducing unnecessary appointments.
Please come back next week IF....
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A phrase doctors and nurses can use at the end of appointments to get patients to come back only when they need to.
Concepts
Long-Term Results Ideas Customer Relationship Management Approach Integrate patient interviews into the doctor appointments and gather knowledge through them. Get to know the parents better and treat them as the subject. eg. frequency of visits, categorise needs and understand parent capabilities. Invest in parents earlier to reduce the need later. Willow Bank can then respond to the parents needs and support them better. Only practice would see this.
Online Patient Profiles Allow patients to access Willow Bank through an online platform with profiles and messaging. From here they could passively ask non-urgent questions, get reassurance from the team at Willow Bank. After doing some research, a website is currently running called How Are You? which looks to manage long term conditions through a similar interface. Testing with this existing system to see if helps patients and reduces their need for appointments.
Health advocates in the community
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concepts
Socially connected patients would be specially trained to help other patients in the community deal with their health care needs and Willow Bank. The health advocates would be trained with a professional recognition, such as First Aid training, and would also be trained to understand Willow Bank’s services. Knowledge of the NHS at large would also help provide navigation assistance for the community.
The Jones Call Message Book -
Interview Notes
Stats
Need help with health education
8 visits in the past 3 months 3 requests for anti-biotics
Nervous about parenting Ask condititions
4 visits for rashes
Concepts
Selected Ideas for Development After a discussion and some reflection, Willow Bank proposed that these three ideas could have the most impact while being the most feasible. They selected two very quick fixes that could have an impact on the surgery and one longer term idea to develop.
Selling the Nurse Practitioner Leaflet Promote the advantages of the Nurse Practitioners, such as extra time and prescriptions, not just what ailments they can treat. Meet our Nurse Practitioners
This idea was well received and would be easy to develop for testing. Picture of the NPs would introduce the patients. Icons would show the users the advantages of seeing the nurse practitioner. A list of conditions presented in everyday terms would educate users on what can be treated.
They have to offer:
More Time
Prescriptions
Education
Book with them for: Colds Flu Rashes Bumps and Bruises
Follow Up Tokens and Phrasing A follow up token to help the receptionists know when a doctor has requested a follow up and when it should be scheduled.
Please come back next week IF....
The token part of the idea was very well received and thought to be something different. There was also a possibility of it being a reminder token. The GP would also have to have a new phrase for patients they thought was ok but might need to return if get worse.
Understanding the Patient better through a Shared Profile Integrate patient interviews into the doctor appointments and gather knowledge through them. Profiles would be open for patient to see. Interview Notes
Stats
Need help with health education
8 visits in the past 3 months 3 requests for anti-biotics
Nervous about parenting
4 visits for rashes
Ask condititions
What Willow Bank Offers
concepts
Call Message Book -
Different services to keep you healthy 1. Health Care Support for ongoing 2. Nurses for blood work and checks 3. Nurse Practitioners for minor illness 4. GP for major or complicated illness
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The practice could work to get to know the patients and this information would be open for the patient to access and update. This information would be accessed by the professional at the start of a consultation in order to get a quick refresher of the patients history and ability.
The Jones
Concepts
First Co-Design Session A co-design session was held with the staff at Willow Bank to develop the three ideas for maximum potential for success in a working practice. Doing this with the staff was essential as their knowledge of the day-to-day workings are an asset which could not be gathered without a great deal of research. This process also help bring the team together and increased enthusiasm for the project in general. By contributing towards the ideas there was a sense of shared ownership. The leaflet was straightforward and the information to be presented was agree upon. As for the tokens, quick samples of were made from laser cut plastic sheet and brought up to so everyone had an understanding of the possible outcome. With these tokens in everyones hands different scenarios were played out and thought through. In the end, it was decided that the tokens would stay inside in the surgery and travel, via patient, between the GP and the receptionist. The token would communicate the professional and the time until the next appointment. With these quick ideas sorted, the longer term idea was explored. The patient profile idea was very loosely defined at the beginning of the session but slowly a clearer picture was defined as the discussion continued. It was important that anything designed should be open between the patient and the practice, this is a trend in health care. Also, the profile needed to quickly communicate the patients information or it would be no use to already pressured professionals. The session finished with a consensus on what the overall framework would be and a plan with what to be done next.
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concepts
Tokens were quickly prototyped with the laser cutter to show the possible outcome. Source: personal photo
A co-design session with staff at Willow Bank was very useful to quickly develop the ideas to level that could work in the practice. The staff`s knowledge of the day-to-day operations at the practice was an asset that could not be replicated without dozens of days spent shadowing. Source: personal photo
Concepts
Leaflet and Token Concept Development 3. Pick when they should be seen again and with whom, then select the appropriate tokens... PRACTI T AL
*
NER IO
OF W EE
NU R
*W
amount of time
i po B
n
n
i po B * A p ow il l
t an m e n t* k Me ir*
t an m e n t* k Me ir *
SE
KS
1. A child and parent comes to an appointment for a new issue...
*
XT WEEK NE
ir*
*W
GEN ER
in
t an m e n t* k Me ir*
po * A p ow ill
nt*
ACT IT
B
If you decide the child needs a follow up appointment...
NER IO
The Tokens
Ap
W il
lo w
professional
4. Give the child the tokens and tell them to hand them in at reception for an appointment. That’s it! 2. You decide the child should be seen again for this issue...
A storyboard was created to explain the system to the staff memeber unfamilar with the project. Source: personal photo
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The tokens and leaflets were quickly designed to deal with demand in the short term while the patient profile concept is developed and tested. Source: personal photo
concepts
The tokens are made from laser cut plastic and can be reused. There are three lengths of time and three professionals to choose from for making bookings. Source: personal photo
Concepts
Second Co-Design Session
55
concepts
A second co-design session was run to get as many staff members and patients inputs as possible for the patient profile concept. The information needed to be what patients felt comfortable sharing with their health care professionals and also the information that would be most useful in helping the health care professional understand the patient. In order to get the right information a set of graphical cards were drawn up with different options for the information that could be represented. These cards were present to people along with an A4 sheet and people were asked to place the cards they wanted. However, the challenge was to pick the most necessary cards as there was not enough room to fit them all. This forced people to make decision about the most vital information. The task was designed this way as there is a limit to how much people can take in and overloading the sheet would be ineffective. The design challenge proved to be successful and 15 different patients and staff members contributed their designs. The task also proved to be a good talking point as it gave people something tangible to talk about and ideas to add their own. A count was performed to find the popular cards for patients and staff to determine the final design.
Concepts
Patient Profile Concept Development The cards that people felt most strongly about were compiled onto one sheet. This blueprint was then worked up on the computer to get a better feel for what the final concept could look like and test readability. After receiving feedback a prototype of a website was built to support the profile allowing patients to view previous appointments, book appointments and manage conditions. This filled out the service proposal for a more complete experience.
The final selection of cards that would make up the patient profile. Source: personal photo
David Taylor about
male born in Stockport, UK
gp visits
a&e visits
past 3 months
past 3 months
past 12 months
past 12 months
born on August 7th 1983 lives at 23 Trentham Road goes to school at LCC
“I get very nervous about visiting the doctor’s office” “I have trouble remembering what the doctor tells me to do” “I wish I could get more explanation and eduction about my health issues” what I want my health care professional to know about me
Debbie Leslie
Sandra Leslie
ME
Partner
Barry Taylor
Dee Taylor
Son
Daughter 6 weeks ago
who lives with me
2 weeks ago
today
my mood
little health knowledge
lots of health knowledge
little health confidence
lots of health confidence
my rating of my skills
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The profile was then developed further on the computer. This is an early version showing the different elements. Source: personal photo
David Taylor
concepts
Partners Mother
Concepts
Patient Profile Concept Testing
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concepts
A test was designed to see the usefulness of the patient profile in a setting as realistic as possible. The prototyping worked by getting patients to fill out a paper version of the online patient profile and hand it into the health professional they were going to see. The health care professional could then look at the profile and see if it helped in understanding the patient. The patients were generally very open to the idea and willing to fill in the form. Most of it was straight forward however the section entitled ``What I want my doctor to know about me`` section was difficult for people to think of something to write. It was felt that this question would require some more reflective time to think about and it proved difficult to come up with something on the spot. When the health care professional received the paper they were supposed to review it quickly and determine the impact it had on the consultation. However, the nurse ran behind quickly and didn’t have time really look through the paper. Although this was disappointing it reinforced the need for the profile to extremely easy to understand as appointments are short and time is very precious. However, the nurse did say she thinks it would useful and she could see it becoming a habit. The feedback on the profile in general was extremely positive with everyone saying it would be useful. Requirements being that it would be the first thing pulled up when searching for a patient and it is extremely quick to read.
Patients were ask to fill out a paper based profile sheet and hand it in to the Nurse Practitioner to test the effectiveness of the profile.
David Taylor about
male born in Stockport, UK
gp visits
a&e visits
past 3 months
past 3 months
past 12 months
past 12 months
born on August 7th 1983 lives at 23 Trentham Road goes to school at LCC
“I get very nervous about visiting the doctor’s office” “I have trouble remembering what the doctor tells me to do” “I wish I could get more explanation and eduction about my health issues” what I want my health care professional to know about me
Debbie Leslie Partners Mother
Partner
Barry Taylor
Dee Taylor
Son
Daughter 6 weeks ago
who lives with me
2 weeks ago
today
my mood
little health knowledge
lots of health knowledge
little health confidence
lots of health confidence
my rating of my skills
concepts
The paper based form version of the profile allowed for easy prototyping of the interaction at very low cost. Source: personal photo
Sandra Leslie
ME
58
This is the digital version of the profile. The profile is designed to share personal details of a patients life to help staff with patients. Source: personal photo
David Taylor
Concepts
Patient Profile Website Testing A prototype of the patient profile website was also built to be tested with staff and patients at Willow Bank. This prototype was to test the functionality and usability of the proposed design. The key features being sought for feedback was an online appointment booking system, consultation history, other services, messaging and long term condition management. The feedback of the website was very promising. Improvement were suggested for the basic design and functions. Comments surrounded adding more information about professionals along with a couple additional features. There was a lot of commentis regarding the appointment system with patients saying they felt more comfortable giving a reason for a consult to a computer rather than the receptionist. All the feedback was taken into consideration for the final design.
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concepts
Many different Willow Bank staff members were ask to navigate through the website prototype. Patients were also asked to use the prototype to get feedback on the functionality and the usability. Most people welcomed the idea of booking online and the options for consultations. Source: personal photo
profile
appointments
medications
other services
messages
diabetes
new page
born on August 7th 1983
David Taylor
lives at 23 Trentham Road about
May 8th, 2012
January 12th, 2012
Rash Reoccurance
Rash Required cream March 10th, 2012
Conjunctivitis Advice given October 30th, 2012
Lung Infection Required anit-biotics
March 10th, 2012
Back Pain Advice given
2012
The case page shows the history of the patients visits to the practice. After testing this was expanded to include phone and email. Source: personal photo
Diabetes
today- November 1
2013
Feburary 30th, 2012
August 10th, 2012
December, 2012
Blood and Diet Check Up
Blood and Diet Check Up
Blood and Diet Check Up
book a new appointment
profile
appointments
medications
other services
messages
diabetes
new page
born on August 7th 1983
David Taylor
lives at 23 Trentham Road about
May 8th, 2012
January 12th, 2012
Rash Reoccurance
Rash Required cream March March 10th, 10th, 2012 2012
send information as:
Conjunctivitis Case: Advice given Conjunctivitis
text message
NHS Choices Information Sympotyms: March 10th, 2012
Back right Pain eye, Puss, Swelling Pink Advice given Advice:
Any consultation could be expanded to show details on that visit for later reference. From feedback, the professionals picture and more info was included. Source: personal photo
Octoberemail 30th, 2012
Lung Infection print out Required anit-biotics
Rinse twice a day with fresh water Apply cold cloth if bothered.
2012
today- November 1
2013
Medication:
None
Diabetes a
Feburary 30th, 2012
August 10th, 2012
December, e 2012
Blood and Diet Check Up
Blood and Diet Check Up
Blood a and Diet Check U Up
book a new appointment
profile
appointments
medications
other services
messages
diabetes
new page
born on August 7th 1983
David Taylor
lives at 23 Trentham Road about
step 1 - appointment type
step 2 - reason for appointment
step 3 - appointment preference
Select a professional:
new
Users found booking new appointments to be easy. Input from staff suggested providing more information on the ailment perhaps could prevent the consultation. Source: personal photo
or
Follow Up Follow Down Follow
Given your selection we suggest: Debbie Practice Nurse Also available: Dawn Nurse Practitioner Dr. Smith General Practitioner
or
existing
Write your own: Start typing here...
Date: November 18th 2012
Lung Infection
add this appointment
Time: 10:00 am
concepts
Follow
cancel this appointment
60
Search our list:
ices
willow ba
nk
Jones
Liverpool,
diabetes
UK
August 7 th
23 Trenth
1980
past 3 months
am Road
Paul’s Au to
past 12 months
gp
a &e
2 1 1 0 5 4 1 1
about visits
ng the doc
he doctor
uction abo
tor’s surge
tells me to
ut my hea
care pro
ry”
do”
lth issues”
+ more t o say l to know about m e
fessiona
Debbie L eslie Mother
h e
lots of he alt knowledg h e
adjust yo
ur ratings
lots of he alt confiden h ce
if you fee
l th
Paula Jo n ME
es
Sam Le
Partne
Barr y Jon e Son
s Dan Jo nes Daughter
Final Design
Health Portrait Overview
63
final design
Health Portrait is a service that connects patients and health professionals while adding depth to healthcare consultations. Patients create a “portrait� which captures specific aspects of their lives which are useful to health professionals when consulting with patients. Health Portrait also keep records of consultations allowing them to be referenced by the patient for previous diagnoses and advice. Patients can also book new variety of consultations types to fit their lives, such as email, phone, online or in person.
64
final design
clockwise from top left: 1. patients meet with a health care support worker to get introduced to the surgery and Health Portrait 2. After creating the profile users get a personalized information sheet on Health Portrait 3. Cards are printed with a summary of the consultation for the patient to review at a later time. 4. Staff at the surgery see the same screen as the patient for total transparency
Final Design
Storyboard
1
Paula and her 2 sons move into a new neighbourhood in Stoke-OnTrent.
2
Paula checks NHS Choices to find the surgeries in her area and chooses one.
1.
2.
my name is born on
day
month
year
about
3.
what I want my health care professional to know about me name
born (DD/MM/YY)
relation
gaurdian / carer
name
born (DD/MM/YY)
relation
gaurdian / carer
name
born (DD/MM/YY)
relation
gaurdian / carer
name
born (DD/MM/YY)
relation
gaurdian / carer
name
born (DD/MM/YY)
relation
gaurdian / carer
name
born (DD/MM/YY)
relation
gaurdian / carer
65
final design
who lives with me
3
Paula contacts the surgery and attends a New Patient Introduction to learn about the practice for her and her boys.
4
Paula fills out a form for the Health Portrait online service. She fills out forms for the boys as well.
6
At home, Paula logs in to update profiles, book appointments, view messages and manage conditions for the family.
7
A few weeks later Paula’s son, Barry, has a rash. Feeling stressed and with no one to social support for advice with she decides to visit the surgery.
8
She goes on to Health Portrait and books an in person consultation for the next day.
final design
Online profiles for Health Portrait are created for the family members. A sheet is printed out with the profile and instructions.
66
5
final design 67
9
At the practice the staff can review the request and ensure that Barry visits the right person.
10
Paula checks Barry in at the surgery and confirms the reason for the visit.
11
The doctor can check Barry’s profile before the appointment to learn more about his family and sees that they are new to the area.
12
The doctor visits with Barry knowing more information about him. He gives Paula a leaflet on rashes and info for a single young mothers play group.
15
A few weeks later, Paula’s family meets up with the play group the doctor suggested and Paula meets with young mums in the area.
14
At home, Jenny can review all her past appointments and message the doctor if she has a question.
final design
The doctor adds the appointment to Barry’s profile with his diagnosis and treatment advice.
68
13
Final Design
Touchpoint Details The portrait tab paints a picture of the patients life, history, skills and current situation. This information creates the patient’s story and brings it to modern health care.
“what I want my health care professional to know about me” is a place for patients to share a personal message which is important to the patient.
Patients can see number of visits to the surgery and a comparison to the average. This gentle reminder hints at the normal amount of visits.
Paula Jones log out portrait
cases
medications
other services
willow bank
diabetes
new condition
Paula Jones female
a&e
gp
born in Liverpool, UK
past 3 months
born on August 7th 1980
past 12 months
lives at 23 Trentham Road works at Paul’s Auto
2 5
1 4
1 1
about
appointment next week
0 1
message from Sue
visits
notices
“I get very nervous about visiting the doctor’s surgery” “I have trouble remembering what the doctor tells me to do” “I wish I could get more explanation and eduction about my health issues” + more to say what I want my health care professional to know about me
little health knowledge
Debbie Leslie Mother
Paula Jones
Sam Leslie
ME
Partner
lots of health knowledge
slide to your mood
Barry Jones Dan Jones Son
6 weeks ago
2 weeks ago
today
final design
“my mood” is for patients to track their mood overtime. This information is useful for the patient and the health professional to see visualized . Feedback showed a lot of enthusiasm for this.
Daughter
lots of health confidence adjust your ratings if you feel they change.
my mood
69
little health confidence
my rating of my skills
“my rating of my skills” let the practice understand the patients knowledge and confidence in order determine how much to education to provide you with and how to deliver it.
edit who lives with me
Knowing “who lives with me” provides the practice with an understanding of what the patients social support network is like and if get to know the family as a unit.
The cases tab is a record the patients consultations with the surgery. This is not a full medical record but provides the useful parts of the vists for patients.
Individual consultations are contained in boxes and can be expanded for more information. This consultations are stored for later referral if needed.
The consultations are organized by time allowing users to easily find a case and view it.
Paula Jones log out portrait
medications
cases
other services
willow bank
diabetes
new condition
born on August 7th 1980
Paula Jones
lives at 23 Trentham Road about
March 10th, 2012
June 24th, 2012
Consultation with:
Consultation with:
Dawn Nurse Practitioner
Dawn Nurse Practitioner
In Person Consultation Type Problem Rash Action Required Cream
In Person Consultation Type Problem Lung Infection Action Anti-Biotics March 10th, 2012
Consultation with:
Dr. Smith General Practitioner Online Consultation Type Problem Back Pain Action Advice Given
2012
today november 1
r 10th, 2011
September 10th, 2012
ion with:
Consultation with:
In Person Consultation Check Up Blood Test
A case is an condition or problem raised and a consultation is a discussion about that case. A case can have multiple consultations but each consultation can only have one case.
Debbie Pratice Nurse In Person Consultation Type Problem Check Up Action Blood Test
Consultations that are related by the same issue are connected by a line.
start a new case
The start a new case button is used to book a new consultation. This change in terms is an attempt to get away from in person appointments.
final design
Diabetes
70
bbie tice Nurse
2013
This is the final screen of the “start a new case” screen. Patients go through steps which guides the options for them and gives advice on how to treat at home.
The patient adds the case to their health timeline and can be sent a text reminder before the appointment. They are provided with information about the ailment to try and resolve the issue themselves.
Paula Jones log out portrait
cases
medications
other services
willow bank
diabetes
new condition
born on August 7th 1983
Paula Jones
lives at 23 Trentham Road about step 2 - who
step 1 - what
Type your reason for visiting:
Select a professional:
step 3 - how
Select how and when to talk: Online Consultation Decribe your problem in more detail and you will get a message back by the end of the day
Headache Given your selection we suggest Dawn Nurse Practitioner and When would you like to talk with a health professional? Today
Anytime
It’s quite urgent to talk with someone.
It’s not urgent and can be anytime.
(In Person Appoinments may not be available)
(All options should be available)
Dawn is a specially trained nurse able to handle a wide variety of conditions. She is also able to give perscriptions more info
Also available Dr. Smith General Practitioner Dr. Smith has been with Willow Bank for 3 years and specializes in treating complex long term conditions. more info
Email Consultation Decribe your problem in more detail and you will get an email back by the end of the day
Phone Consultation You will be called back for a consultation at the time you select. Confirm this number is correct: 07565 424051
Time: 10:00 am In Person Consultation Face to face appointments are available with Dawn below
start a new case
Date: November 8th 2012 Time: 10:00 am
71
final design
next
In step 1 patients give a reason for wanting a consultation and the urgency of the issue. This helps find the most appropriate person for the patient to talk with about the issue.
next
In step 2 the patient can select the health care professional to have the consultation with. A professional will be suggested based on the reason allowing nurses to be promoted when appropriate, giving GPs more time.
cancel new case
Finally, step 3 is where the patient selects the type of consultation and when it happens. There are four options for the patient: online, email, phone and in person. These options have different advantages for patients depending on the need.
Long term conditions are another major feature of the Health Portrait. This allows for patients to have ongoing dialogue of the condition with their professional.
Paula Jones log out medications
cases
portrait
other services
willow bank
diabetes
new condition
born on August 7th 1980
Paula Jones
lives at 23 Trentham Road about
blood suger levels
weight
24
90 Paul My levels are being a little less stable since I started taking this prescription. Side effect?
12
75
2 42 43 44 45 46 47 48
NHS Choices http://www.nhs.uk/Conditions/Dia betes/Pages/Diabetes.aspx What Do I Eat Now? - Book Library Link The Diabetes Cooking Book Library Link
60
my goals
“Keep a better watch on my levels in the morning” “Manage my weight better through better eating” “Discover more foods that can help my condition”
This screen is setup for diabetes but similar ones could be designed for any number of conditions with easy modules.
Dr. Smith - General Practitioner Sept 2th There is no medical reason for changes. Maybe you should come in soon for a check. Paul Thanks for the advice at the appointment yesterday. I think swimming will work well for me.
Oct 10th
Dr. Smith - General Practitioner Oct 18th Hey. I heard the local leisure centre is having aquafit on Tuesday nights. Start typing here...
post message
Monitors could get results from smart devices like blood sugar readers. The space could also be used for setting goals and educational materal.
Messages could be sent to the patients condition manager about non-urgent issues or concerns.
final design
information Diabetes UK http://www.diabetes.org.uk/
Sept 1st
72
10 11 12 13 14 15 16 17
messages
Paula Jones log out cases
portrait
medications
other services
willow bank
diabetes
new condition
born on August 7th 1980
Paula Jones
lives at 23 Trentham Road about
medications
Name
Dose
Conditions
Breakfast
Potassuim
1 x 200 mg tablets
Eat with food
Anti-Biotic
2 x 300 mg tablets
Take with liquid
Paracetamol
2 x 500 mg tablets
Take with liquid
Long Acting Isulin
30 Units
Take before bed
Lunch
Dinner
Evening
New Medicine
The medication tab shows the patients perscriptions and relevant information on those drugs for the patient.
Paula Jones log out cases
portrait
medications
other services
willow bank
diabetes
new condition
born on August 7th 1980
Paula Jones
lives at 23 Trentham Road about
what I need help with
services currently accessed I would like some help with:
Health Visitor Lynn
Parenting and Food Sure Start - Classes
Contact: Phone 07673 918347 email: lynn@nhs.co.uk
Recommended by Lynn www.surestart.co.uk
What to Expect in the First Year - Book Recommended by Jakie www.whattoexpect.com
Triple P Heather
Parenting Guide - Website
Contact: Phone 07673 918347 email: heather@nhs.co.uk
I would like some help with:
The other services tab shows the help that the patient is recieving from other agencies. Also its a space to ask for help on any subject and get suggestions from the surgery.
Recommended by Dr. Smith http://www.nhs.uk/Tools/Pages/Parentingselfassessment
post topic here enter topic here to get advice from your service providers
Housing Assistance John Contact: Phone 07673 918347 email: john@gov.co.uk
Paula Jones log out portrait
cases
medications
other services
willow bank
diabetes
new condition
born on August 7th 1980
Paula Jones
lives at 23 Trentham Road about
questions for the practice
final design
Phone 0300 123 5002
10:15 am Oct 7th
Sue - Reception I had a look and the pharmacy will drop it off around 2pm. Anytime after that!
11:39 am Oct 7th
Paul Will there be a nurse available this evening for flu shots?
4:55 pm Oct 26th
Sue - Reception Yes, Paul. Deb is available this evening. She still has 5 spots available.
5:45 pm Oct 26th
Hours Monday-Friday 8am - 8pm Saturday 8am - 12md
Services Offered The team offer the full range of primary care medical services. These include: General medical advice - led by our doctors Childhood vaccination and immunisation led by our nurse practitioners Adult acute and chronic conditions led by our Nurse Practitioners
73
Paul Do you know if my perscription will be available today?
Start typing here...
post message
The surgery tab provides basic information on the surgery. There is also space to ask general questions the reception staff could answer, such as if a perscription is ready for pick up.
Paula Jones log out portrait
medications
cases
other services
willow bank
diabetes
new condition
born on August 7th 1980 1983
Paula Jones
lives at 23 Trentham Road about
March 10th, 2012
June 24th, 2012
Consultation with:
Consultation with:
Dawn
Dawn Nurse Practitioner
Consultation Record Nurse Practitioner
online consultation In Person Consultation Type Problem Lung Infection Action Anti-Biotics
March 10th, In 2012 Person Consultation Type Consultation Rashwith: Problem Dr. Smith Cream Action Required
General Practitioner
March 10th
March 10th, 2012
Paula My back is very stiff and especially hurts in the morning. Is there anything I need to be worried about?
Consultation with:
Dr. Smith
Type Problem
Online ConsultationGeneral Practitioner Back Pain Online Consultation Type Links: NHS Choices Back Pain ProblemInformation Action Advice Given Patient.co.uk
Symptoms
Lower back stiffness. Especially noticable in morning.
Action
Stretching before bed and warm compress in morning. Contact again after 1 month if still present.
2012
r 10th, 2011
ion with:
bbie tice Nurse
Dr. Smith - General Practitioner Nothing to be worried about. Try stretching of an evening. Any new today chairs or funiture your sitting in?1 november
2013
Paula September Now you mention it,10th, I did2012 get a new car. I’ll Consultation adjust the with: settings Debbie and try stretching. Thanks!
Diabetes
start a new case
Pratice Nurse
Medication None
In Person Consultation Check Up send information as: Blood Test
Type
Start typing here...Problem Action
text message email
book follow up consultation
print out
In Person Consultation Check Up Blood Test
post message
When the patient clicks on any consultation more information becomes available. This is useful to see what action was recommended for similar previous cases.
Paula Jones log out portrait
medications
cases
other services
willow bank
diabetes
new condition
born on August 7th 1980
Paula Jones
lives at 23 Trentham Road about
March 10th, 2012
June 24th, 2012
Consultation with:
Consultation with:
Dawn Comfirmation of Consultation Nurse Practitioner
Dawn Nurse Practitioner
online In Person Consultation Type Problem Lung Infection Action Anti-Biotics
November 8th, 2012
In Person Consultation Type Consultation with: Problem Rash Dawn Action Required Cream
Nurse Practitioner Dawn is a specially trained nurse able March 2012 to handle a wide variety of10th, conditions. She is also able to give perscriptions Consultation with:
Consultation with:
Type
Dr. Smith Online Consultation General Practitioner
Problem
Headache
2012
r 10th, 2011
Dawn Nurse Practitioner Online Consultation Type Problem Headache Action waiting for message
Online Consultation Type Problem Back Pain Action Advice Given
Before your consultation you might find the information on these websites useful. If you feel you can handle the problem on your own please cancel your appointment. Thank You.
2013
today november 1
Paula I’ve been have this headache for the September 10th, 2012 past couple days. I’ve tried pain Consultation with: killers but it comes back. Should I be Debbie worried? When should I come Pratice Nursein?
ion with:
bbie tice Nurse
consultation
November 1st, 2012
Links: Headache - NHS Choices Diabetes Headache - Patient.co.uk
In Person Consultation Check Up Blood Test
Type
Start typing here...Problem Action
confirm consultation
start a new case
In Person Consultation Check Up Blood Test
post message
Once the patient has selected their consultation options a confirmation screen is shown. On this screen, links to relevant information is shown with the hope the patient is able to resolve the problem.
Paula Jones log out portrait
cases
medications
other services
willow bank
new condition
Barry Jones a&e
past 3 months
born on April 7th 2006
past 12 months
lives at 23 Trentham Road goes to Sure Start Nursery
2 4
2 8
1 1
about
appointment next week
0 2
message from Sue
visits
notices
“I have been getting stressed over Barry’s coughing at night. It really difficult in the middle of the night” “I wish the doctor would listen when I want anti-biotics” Debbie Leslie
what my carers want my health care professional to know about me
little health knowledge
2 weeks ago
today
Sam Leslie
Father
Partner
Barry Jones Dan Jones ME little health confidence
Daughter
lots of health confidence adjust your ratings if you feel they change.
my mood
Paula Jones lots of health knowledge
slide to your mood
6 weeks ago
Mother
my carers rating of their skills
edit who lives with me
If the patient is a parent, gaurdian or carer then they will have the rights to access the person under their care, as well to book consultations and share information about them.
final design
gp
born in Stoke-on-Trent, UK
74
male
Welcome to Willow Bank! In order to provide the best service we are looking to better understand you and your health. To provide that service we would like you to share some information with us, fill out as much as you feel comfortable. Thank you!
1.
2.
my name is born on
day
month
year
about
3.
what I want my health care professional to know about me name
born (DD/MM/YY)
relation
gaurdian / carer
name
born (DD/MM/YY)
relation
gaurdian / carer
name
born (DD/MM/YY)
relation
gaurdian / carer
name
born (DD/MM/YY)
relation
gaurdian / carer
name
born (DD/MM/YY)
relation
gaurdian / carer
name
born (DD/MM/YY)
relation
gaurdian / carer
In this section you can tell the doctor or nurse something you would like them to know. Could be something like: “I get nervous when visiting the Doctor’s office” “I worry a lot about my child’s health and would like more explanation” “I have a chronic condition that is a big part of my life”
little health knowledge
lots of health knowledge
who lives with me
little health confidence
lots of health confidence
my self-rating Please shade in the level of health knowledge and confidence you feel you have. This will help us to know what health information we should provide you with during your appointments.
Seeing who you live with can help us get to know your social health care support and see if any health issues are related. Let us know if you need another sheet for more than one household or more space.
This is the form for new patients to fill out when first meeting with the surgery. The information patients give over during this form is used to create a online portrait. The form is designed to be more interesting to fill out than traditional forms. In the future, a laptop could be used for the patient to input the information directly.
Consultation Record March 10th, 2012
Consultation with:
Dr. Smith General Practitioner
Type Problem
Online Consultation Back Pain Links:
75
final design
http://www.nhs.uk/conditions/headache http://www.patient.co.uk/health/HeadacheChronic-Tension-Type.htm
March 10th
online consultation
Paula My back is very stiff and especially hurts in the morning. Is there anything I need to be worried about?
Symptoms
Lower back stiffness. Especially noticable in morning.
Dr. Smith - General Practitioner Nothing to be worried about. Try stretching of an evening. Any new chairs or funiture your sitting in?
Action
Stretching before bed and warm compress in morning. Contact again after 1 month if still present.
Paula Now you mention it, I did get a new car. I’ll adjust the settings and try stretching. Thanks!
Medication
None
The consultation record can be given to the patient for reference at home. This came from a finding that patients find it difficult to remember what the health professional has told them.
Welcome to Health Portrait! This online service helps you share more information with your medical professional. This information will help the medical professional understand you on a deeper level and provide better insights in your health issues. Health Portrait also lets you book consultations with all the medical professionals through a bunch of a different methods, such as email, phone or online messages. Log in at home and explore the website! Login using your name and birthday. Your password is: sharing some key un-asked information with the practice allows you to bring to attention something which is important to your life.
the about section shows your basic information and your employment could be changed at anytime.
visits let the practice see if you usage has increased and inquire the reason for this.
Paul Jones portrait
cases
medications
other services
willow bank
diabetes
log out
new condition
Paula Jones female
a&e
gp
born in Liverpool, UK
past 3 months
born on August 7th 1980
past 12 months
lives at 23 Trentham Road works at Paul’s Auto
2 5
1 4
1 1
about
appointment next week
0 1
message from Sue
visits
notices
“I get very nervous about visiting the doctor’s surgery” “I have trouble remembering what the doctor tells me to do” “I wish I could get more explanation and eduction about my health issues” + more to say
Debbie Leslie
what I want my health care professional to know about me
little health knowledge
lots of health knowledge
little health confidence
lots of health confidence
slide to your mood
Mother
Paula Jones
Sandra Leslie
ME
Partner
Barry Jones Dan Jones Son
today
adjust your ratings if you feel they change.
my mood
my mood is for you to track you mood overtime. this information could be useful for you and your doctor to see.
my rating of my skills
my health knowledge and confidence let the practice understand your skills better and determine how much to education to provide you with.
Son edit who lives with me
knowing who you live with can provide the practice with an understanding of what your social support network is like.
After the patient’s information has been entered and a portrait has been created, a personalized introduction sheet is printed and mailed to the patient. This sheet introduces and explains the service while inviting the patient to go online and finish creating their account.
final design
2 weeks ago
76
6 weeks ago
Final Design
Customer Service Journey Pre-service Find
New Patient Introduction
Portrait profile form is given and filled out
Service Encounter Register
Health Portrait personalized welcome sheet is given
Evaluate at Home
Make Appointment
Refers to previous consultations online
Starts new consultation on Health Portrait
Refers to previous consultations cards received Call to reception to make new consultation
Call surgery to ask questions
Go to reception to make new consultation
77
final design
Care Support Worker intros Health Portrait
Search websites like NHS Choices
Refers other websites such as patient.co.uk
Service Encounter Check In
Professional Reviews
Symptoms
Professional reviews reason and offers advice over Health Portrait
Check in with reception if problem or more requests
Reminder to go to consultation
Self Care
Reflect
Recommended action is recorded on website
Website record can be refered to for advice
Can add reflective notes to own “Portrait”
Recommended action is printed for access at home
Paper record can be refered to for advice
Professional reviews reason and calls patient to consult
Symptoms are explained and recorded
Recommended action is given in verbal form
“Portrait” acts as prompt for deeper discussion
Symptoms are explained, observed and recorded
Recommended action is given in verbal form
Professional reviews reason and emails advice to patient
Reminder to go to consultation
Action
Recommended action is emailed to patient
email record can be refered to for advice
Recommended action sent to patient as text message
Action record can be refered to for advice
Refers other websites such as patient.co.uk
final design
Check in with computer
78
Prepare
Post-service
Final Design
Consultation Type Journey Map Consultation Type (for GP and NP)
Easy
Easy
Moderate
Limited
(projected)
10
5
8
12
Urgency
Non Urgent
Non Urgent
Urgent
Both
Time Frame
Within 1 Day
Within 1 Day
Method
Computer Smart Phone
Computer Smart Phone
Phone
In Person
Selects online consult and adds more information / question
Selects email consult and adds more information / question
Selects phone consult and selects date/time
Selects in person consult and selects date/time
Message email is sent to appears to staffs inbox. Staff Notification prompt reply. Normal email Notification notification. before shift end.
Consult is added to appointment schedule of professional.
Consult is added to appointment schedule of professional.
Consultation In Clinic
Time is alotted at the begining, middle and end of clinical sessions.
Time is alotted at the begining, middle and end of clinical sessions.
Professional phones patient when appointment time arrives.
Professional meets with patient when appointment time arrives.
Consultation Not In Clinic
Message will email will wait appear at until the start of begining of next next clinical clinical session. session.
Phone consultation can’t be booked
In person consultation can’t be booked
If running late, patient is called by reception and consult is moved to last.
If running late, patient waits in waiting room until seen.
Consult Access
Details
Consults per Day
79
final design
Actions
User Selection
If not replied to within 1 work Back Up day then patient is asked to send to new person.
Patient is told before hand that emails for non-urgent.
Within 4 Hours On Day/Advance
Final Design
Emis Web
80
final design
The online part of the service concept has been designed with emis web in mind throughout the entire process. emis is the software system currently used Willow Bank and thousands of other practices across the UK. emis is used for keeping patient records, tracking QOF, booking appointments and internal communication. Recently, they have added online appointment for patients to access but the functionality is limited to advanced bookings and has no personal information. Technically, many of the functions of the proposed could integrate easily into emis without requiring additional work for the health professional or reception. For example, the consult records for Health Portrait could pull data from the patient full medical records which already include reason, symptoms, recommendations, action and medication. Currently the system recommends a professional for certain ailments when the reception is booking appointments, this could be expanded and developed for when the patient books consultations. The acceptance of the new service should be high in practices through ensuring it works with well with emis and integrates into the way practices work.
Final Design
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Conclusion Health Portrait aims to improve the relationship between patients and health professionals in the GP surgery in order to reduce the need for face to face consultations for ailments that are treatable at home. This project started with a GP surgery listening to its patients who were having to call repeatedly first thing in the morning to try and get an appointment. Basically, high demand was outstripping the supply of appointments. The surgery felt it was being burdened by patients requesting appointments with minor ailments which could be treated at home. The high demand for these minor issues were having negative impacts on the GP surgery staff and on a national level, huge financial costs across the NHS. Research looked at the context of the larger health system, health history and demand management to understand the how this issue has evolved and its impact. Understanding what the GP surgery provides and how it operates was vital to making any designed solution be appropriate for the staff. At the same time, learning the patient’s stories was the key to seeing that people were visiting the GP for reasons hidden beneath the surface of the minor ailment. These reasons are so varied that there is no one solution for every patient and health professionals need tools to understand each patient’s personal situation. The idea to allow better sharing of information between patient and professional is at the heart of Health Portrait. At the same time the new service looks to solve other problems for the patient such as navigation, options for consultations and open information. The concept of Health Portrait was developed and tested in a GP practice with the patients and professionals. The test, which asked patients to fill out a paper version of the portrait and hand it over to the nurse, proved the concept had merit and could be useful in a practice for both patient and professional. People who used the Health Portrait prototype website found it easy to navigate and said it was far better than any online appointment system they have used yet. All the feedback was taken into consideration and most was included into the final design. The positive results from testing show the idea has a solid foundation and could be carried forward for further testing. The main recommendation is for another test of the “portrait” to make sure the information is useful for the professionals and is quick to read. This test would have to happen over a long period with dozens of “high use” patients filling out the form and it being added to their file. This way the test could happen over weeks and the ability for professionals to help curb the patients use would be a clear indication success. Additionally, a test of the new appointment would have to be
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designed to see what the usage of different appointments would be like and plan appropriately. The best method for this test would be to put a nurse on the phone during the rush and get patients to give the reason for the visit. The nurse could then sort the appointments to the appropriate professional in an efficient manner, including calls and emails. These two tests would confirm if the new service could really function successfully but would take time to achieve. Health Portrait is a new service for GP surgeries which aims to improve their relationship with patients. The modern medical system has improved the health of millions but in the quest for efficiency there are now many different professionals for patients to see and the time for appointments is limited. The effect of this efficiency is a reduction in the amount any one professional can possibly know about a patient. Fragments of the patients story are scattered across the surgery with different people. Health Portrait allows patients to create their whole story in one place and share it with the people who care for them.
References Butler, P. (2012) History of NHS reforms: A state of permanent revolution. Guardian, [online] Friday 9 July 2010. Available at: http://www.guardian.co.uk/society/2010/jul/09/nhshistory-reforms-health-policy [Accessed: July 13 2012]. Choosewell.org.uk (2012) NHS :: Choose well. [online] Available at: http://www. choosewell.org.uk/ [Accessed: 21 Nov 2012]. Department of Health. (2009) Healthy lives, brighter futures – The strategy for children and young people’s health. Department of Health. (2010) World class commissioning for GP services: Improving GP Access and Responsiveness. Designcouncil.org.uk (2010) Design Council - Lewisham Council. [online] Available at: http://www.designcouncil.org.uk/our-work/leadership/Public-Services-by-Design/Casestudies/Case-Study-Lewisham-Council/ [Accessed: 13 Jul 2012]. GP Patient Survey (2011). ‘Practice report’. GP Patient Survey website. Available at: www. gp-patient.co.uk/results/weighted/practicereport/ (accessed on 18 March 2011). Hunter, M. (2012) Redesigning public services: happier customers cost us less. Guardian, Tuesday 10 July 2012. Jaimie, K. (2012) GP ‘cottage industry’ not fit for purpose, says Kind’s Fund. Pulse, 6 September. Jones, T. (1997). The structure of the National Health Service. Beckenham, Pub. Initiatives. Murkoff, H. E., Eisenburg, A., Mazel, S., Hathaway, S. E., & Eisenburg, A. (2003). What to expect the first year. New York, Workman Pub. Martin, S. and Dunbar-Rees, R. (2012) Why GP surgeries need crowd control. BBC News, [online] 13 April 2012. Available at: http://www.bbc.co.uk/news/health-17548240 [Accessed: 13 July 2012]. Meroni, A. and Sangiorgi, D. (2011) Design for services. London: Gower. Nhs.uk (1948) NHS history. [online] Available at: http://www.nhs.uk/NHSEngland/thenhs/ nhshistory/Pages/NHShistory1948.aspx [Accessed: 13 Jul 2012]. Parker, S. and Heapy, J. (2006) The Journey to the Interface: How Public Service Design Can Connect Users to Reform. Demos, 26 July 2006.
Platts A, Mitton R, Boniface D et al. Can self-care health books affect amount of contact with the primary health care team? Scandinavian Journal of Primary Health Care. 2005; 23: 142–8. Improving the quality of care in general practice: The future of general practice. (2011) . The King’s Fund. http://www.kingsfund.org.uk/publications/gp_inquiry_report.html Good, M, Cara, J and Good, B (2005). The Blackwell companion to social inequalities. Chapter 17: The Culture of Medicine and Racial, Ethnic, and Class Disparities in Healthcare. Malden, MA, Blackwell. Seedhouse, D. (2001). Health: the foundations for achievement. Chichester, UK, Wiley. Seedhouse, D. (1998). Ethics: the heart of health care. Chichester, John Wiley. Silvester, K. and Lendon, R. (2004) Reducing waiting times in the NHS: is lack of capacity the problem?. Clinician in Management, 12. Stickdorn, M., & Schneider, J. (2011). This is service design thinking: basics, tools, cases. Hoboken, Wiley. Timmins, N. (1995). The five giants: a biography of the welfare state. London, HarperCollins. Tisman, A. Driving the self care agenda (2008) [online] Available at: http://www.pagb. co.uk/ information/PDFs/AndyTismanarticle.pdf [Accessed: 21 Nov 2012]. Ward, J. (2012) There is a good reason why GP receptionists are so grumpy. Daily Mail, 3 January 2012.
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Fill out all the major points in your families life so far. Start from when you first found out you were pregnant with your first child and mark how many years ago that was. Mark events such as: classes, gp appointments, birth, health issues, periods of high GP use, periods of lower GP use, school, etc. Mark these steps for all your children.
1. Family Healthcare Timeline
Tools:
Insights
2
Some examples are: - Mum - Neighbours - Friends - Doctor - Google - NHS Direct - Books - Class - Experience - Other
Use this sheet to identify all people and resources you turn to for health information concerning your children.
2. Health Care Information
Tools:
Insights
Resources
People
You
Often
Less Often
Other
Places
Try to think of each step in your last visit to each of the listed health care settings. Start with the first symptom and go right through to the resolution. Think about: What were the first symptoms? Did you seek extra information? How did you decide where to go? Did you make an appointment? How did you get to get to the facility? What happened during the consultation? Did you receive treatment advice? Did you get medication? Did you have a follow up visit?
3. Health Visits Timelines
Tools:
Insights
Decision
Decision
Transport
Transport
Decision
First Symptoms
Decision
Last Home Care Experience
First Symptoms
Transport
Transport
Last Out of Hours / Minor Injuries Visit
First Symptoms
Last A&E Visit
First Symptoms
Last GP Visit
Consultation
Consultation
Consultation
Consultation
After Visit
After Visit
After Visit
After Visit
Follow Up
Follow Up
Follow Up
Follow Up