NHS Project by Alison Prendiville

Creating Notions of Value through the Communication of Costs to NHS Patients

23 - 11 - 11

Amy Ricketts

MDes Innovation and Creativity in Industry London College of Communication

PROJECT SUMMARY

THANK YOU

This project began with a hypothesis rather than a specific problem in mind; the idea that NHS patients would value the service more if they knew the cost of their care.

I would like to express my thanks to a number of people who have assisted with this project over the past five months.

Which prompted the question - ‘what is value?’. See appendix item: A

Services by their nature are intangible (see appendix). Users don’t consume services in the same way as products, and this is especially true of health service users. It is for this reason, judging the value of a service proves difficult and we look for cues to set our benchmarks of expectation (see appendix). As with most health services, the NHS offers very little in the way of cues; patients often don’t know whether they have experienced a good or bad service even after an encounter (see appendix). This problem is complicated further when thinking about publicly funded services or ‘non-market’ (Harford, 2007, p.68) systems, where the users are not in control of how their money is being spent. This project proposes a transparent conversation between the service user and provider; showing each patient exactly what the service provides for them personally, in return for their contributions.

Thank you to friends and family who participated in the sessions; who answered many questions and offered feedback. The discussions and insights have been invaluable to the process. Thank you to Daniel Steenstra for the advice and assistance to develop and realise the potential of this project. Thank you also Simon Potter for our discussions at the start and end of this project. The input has been both interesting and challenging. Thank you Dr. Vijay Nayar for advising throughout. Reading a GP’s perspective gave another dimension to the direction of the work. Thank you to Dr. Helena Posnett from Imperial College, who very kindly sent her written thesis which explored similar ideas. Finally thank you to Alison Prendiville and Cordula Friedlander who have provided support and many hours of their time throughout the year.

This report follows each stage of the project, from speaking with patients about how they see value within the NHS and define ‘valuefor-money’, to economic theories around perception of price and value; highlighting the complexities of human choice and behaviour. Purely conceptual, the result of this project are two possible solutions for communicating costs, aimed at two different types of service user.

INTRODUCTION 8 9 10 13

OUTCOMES

Project aims and limitations Outlook for the NHS Patient expectation Increasing service transparency

BACKGROUND 16 18 20 21 22 27

Control and responsibility The power of information Make information relevant Consider the context Message and language Existing work

CO-INSIGHT 30 31 32 43 44 46 48 52 56 58 64 66

The sessions The participants Questionnaires User Journey mapping Value within services Value within the Health Service Guessing the costs of services Guessing the costs of treatment Conscious of consumption? Drawing value Discussing value Feedback on initial prototypes

Contents

70 72 74 77 78 98 101 105 113

Developing the outcomes Project briefs Initial ideas Outcome one - Personal Annual Health Report Service process Service description Outcome two - Diabetes Appointment Planner Service description Intervention positioning

PROTOTYPING 116 117

Testing Feedback

EVALUATIONS 124 126

Conclusions Further development

SUPPORTING MATERIAL 128 134

Bibliography Appendix

Contents

Introduction

PROJECT AIMS AND LIMITATIONS

OUTLOOK FOR THE NHS

The conceptual nature of this project means the outcomes are not complete solutions. Rather, they are suggested ways in which cost amongst other data about a user’s health care might be communicated in an appropriate and valuable way to patients, in the form of service interventions.

As with many of the UK’s public services, the NHS is undergoing huge financial challenges (Campbell, Meikle, 2011) and a potential re-structuring of the way in which the service is delivered (The Telegraph, 2011).

This project does not seek to solve a set of specific problems, such as reducing waste, do-not attends or improving medication compliance. It does however encourage a change in public perception of the service which may have subsequent knock-on effects upon the aforementioned current problems. The proposal has highlighted some contentious issues for people, patients and medics alike, with many suspicious of further spending of NHS budgets towards intangible benefits. The information is currently disclosed on a need to know basis, with tax payers left unaware of the costs of care. Throughout the project, there have been a number of instances where it is felt things should remain this way. This report addresses these concerns, creating an important and compelling case for the service to be much more transparent with patients.

With a target of £20bn in efficiency savings by 2015 (Campbell, Meikle, 2011), the service is under immense pressures to find savings where possible, without compromising patient care. The country’s ageing population is set to reach 15.5 million people over the next 20 years; that’s an increase of just over a third of the current figure (Cracknell, 2010). This is expected to have considerable financial implications, with average health spending for retired households totalling nearly double that for non-retired households (Cracknell, 2010). As demand surges and services are stretched, the public are continually updated by media reports. And, although the public are often seen to be fiercely protective over the future of the service organising protest marches (Taylor, 2011) showing their support, there is also a huge amount of avoidable patient led waste. According to the National Institute for Health and Clinical Excellence, up to 50% of prescribed medicines are used incorrectly (NICE, 2009). Not only are huge amounts of prescription medicines not being taken correctly, ‘in any 12 month period, up to 6 million GP and hospital appointments are missed at an estimated cost of more than £700m across the UK’ (Hitchcock, 2011). Furthermore, ‘the last decade has seen a 42% increase in those turning up with routine medical complaints’ (Campbell, 2011) to A&E. Within the realms of this project it is not realistic to suggest these kinds of problems would be solved. They are complex issues linked to a range of behavioural barriers. However, it is possible to propose that informing patients of their personal usage, would alter their perceptions of the service, the results of which would not be clear without extensive trialing.

Introduction

PATIENT EXPECTATION As this project attempts to address public perception around the value for money of the NHS, it is worth briefly touching upon some existing research into user expectation and entitlement. There have been a number of different surveys that collect quantitative data on patient satisfaction; in particular those published by Ipsos Mori show that 39% of people consulted, felt the biggest problem facing the NHS was a lack of resources and investment (Ipsos Mori, 2011).

69%

Agree that the NHS provides good value for money to taxpayers (Ipsos Mori, 2011)

25%

Agree that the NHS is getting better at managing its budgets (Ipsos Mori, 2011)

77%

85%

Agree that there is waste and inefficiency in the NHS (Ipsos Mori, 2011)

Agree that the NHS will face a severe funding problem in the future (Ipsos Mori, 2011)

Introduction

Agree that the NHS should provide the most effective drugs and treatments provided they represent good value for money (Ipsos Mori, 2006)

28%

40%

Agree that the NHS should provide only the most effective drugs and treatments no matter how much they cost (Ipsos Mori, 2006)

31%

Agree that the NHS should provide all drugs and treatments, no matter how much they cost (Ipsos Mori, 2006)

With resources growing ever tighter, the NHS announced in October 2011 their plans to cease funding of minor operations such as ingrowing toenails and mole removals, telling patients that they would have to use private services (Ramesh, 2011). This may be indicative of the kinds of financial sacrifices that the service will make over the next few years; as patients have to pay additional costs to cover health treatment, public perceptions of value for money will no doubt alter. Capturing patient opinion accurately is a difficult task; Hart and Milstein describe the value created within health care as a ‘complex amalgam of patient satisfaction with many different facets of their experience’ (2003. Cited in Sargeant, 2009, pp.382) Many factors can combine to form opinions about services. The Kings Fund state - ‘public attitudes towards health care are influenced by many factors, including personal accounts by patients of their own experiences, shared with their own informal networks;

Introduction

INCREASING SERVICE TRANSPARENCY regulators’ reports; the media; the organisations that lobby on behalf of patients, NHS organisations and health care professions; commercial suppliers to the health care industry’ (Coulter, Fitzpatrick and Cornwell, 2009). Because the heath service in particular is one dealing with high levels of intangible and often ‘hidden’ aspects of delivery, it’s possible to suggest that patients find it difficult to judge the value of care. Sargeant explains that it is ‘...possible for a patient to leave a hospital dissatisfied with the service they have received, even if their operation was performed to the very highest of technical standards’. (Sargeant, 2009, pp.381)

Lack of transparency from the NHS further removes patient understanding of the impact of their care. As a result, patient dissatisfaction and confusion can arise. This report will go on to explore the underlying problems associated with public perceptions of tax-funded services, specifically the National Health Service. Furthermore, the potential impacts and benefits of creating awareness will also be discussed as part of the proposition for service interventions.

By providing what Health Care Innovation Strategist, Demetrios Perdikis describes, as a ‘framework’ (2009) that takes into account a range of service aspects, patients are able to make more accurate and informed judgements. This has many benefits; adding value in itself, as well as communicating value to patients . Zeithaml and others, encourage this approach; ‘making customers aware of hidden evidence of a company’s commitment to quality service could improve customers’ service perceptions. Customers who are aware that a company is taking concrete steps to serve their best interests are likely to perceive a delivered service in a more favourable way’ (Zeithaml, Parasuraman and Berry 1990, pp.45).

See appendix item: A

Additional background research of service expectation and satisfaction has been conducted prior to this report. This can be found in the appendix.

Introduction

Background

CONTROL AND RESPONSIBILITY The NHS is funded through what economist, Tim Harford refers to as a ‘non-market system’ (2007, p.68). ‘Market systems’ differ from tax-funded systems; ‘in a market system the truth would emerge about how much it costs to provide good schools, and who would be willing to pay for them. The non-market system struggles with these basic questions.’ (2007, p.69) In other words, ‘...the nonmarket system suffers from a serious problem: the truth about values, costs and benefits has disappeared.’ (2007, p.68) Harford explains that market systems reveal preferences; consumer choices of willingness to pay for goods create ‘truth’. The nature of tax-funded services means those who contribute have very little or no say in how their money is being spent. ‘...if a police officer is rude or incompetent, you don’t have the option to shop for a different police force. If you think that the level of police protection you receive is excessive, it’s not up to you to cut back a bit. Neither can you spend more if you decide that you’d like extra service.’ (Harford, 2007, p.68) This lack of control and information leads to service users not being able to judge the value of what we receive let alone have any real say over how things are being run on our behalf; ‘We think that the value we get from schools and police are more than what they cost us in taxes, but we don’t know for sure’. (Harford, 2007, p.70) The alternative however, of privately run, ‘market systems’ face equal challenges and opposition (McCabe and Kirkpatrick, 2011), therefore bodies such as the National Institute for Health and Clinical Excellence make the decisions for us. As Harford explains, ‘the basic challenge confronting the National Health Service is that it has a limited amount of money to spend and an unlimited number of ways of spending it. It is no good asking patients, who pay little or nothing for treatment and will as a result demand more of everything’ (2007, p.130) Considering that users pay for the provision and running of these services, but are given practically no responsibility for or information about how money is spent, it is possible to understand how problems around wastage, dissatisfaction and misuse

Background

undermine the long-term sustainability of the service. Sociologist, Elizabeth Shove has outlined the key factors that influence behavioural practices. In her talk entitled ‘Extraordinary Lecture’ (Shove, 2011). Shove describes the four aspects that fall under the headings of: - Habits (what people do, what becomes routine) - Cognition (what they know and the skills they have) - Meanings (how people make sense of things) - Artefacts (things, technologies, infrastructures) By applying this model to illustrate how the NHS creates patient practices, it becomes apparent that although users are encouraged with increasing regularity to become more personally responsible (The NHS Choices phrase is “Your Health, Your Choices”), the system itself does not and in some cases cannot support this approach: Habits

Cognition

Meanings

Artefacts

Patients can only wait to be told what it wrong, therefore remain passive for much of the ‘journey’

This is because as patients, we lack information and expertise

A visit to the Doctor is generally associated with negative feelings around illness

Often met with time short, staff and generic processes designed to meet the needs of the service

Lack of ownership, participation and heavy reliance places the patient in a difficult position; being encouraged to take accountability for their own service use on the one hand, with no opportunity of control or awareness of impact on the other.

Background

THE POWER OF INFORMATION This project proposes that through increased awareness around service use, patients will be better positioned to understand the value of NHS care. Although in this instance patients would not have control over spending, some parallels of concept can be drawn with personal health budgets. These are allocated amounts of money offered to patients with long term health conditions, to better manage their care. Patients are given a set budget and through consultations with a health care professional can decide how they would like their budget to be spent to better suit their needs. (DOHa, 2011) Sandie is a patient who has been involved as part of the pilot programme. An interview with Sandie can be found on the Department of Health website, where she describes how her personal health budget also act as a health record; “... I know where I’m at. The Doctors are there, the people that care for me, the supplements I need… It’s all down on a piece of paper in one booklet, and I find that quite empowering” (DOHb, 2011). Her husband Arthur adds; “It’s like a snapshot of your life…what’s good, what’s bad, what works what doesn’t, and how things can be improved and how much that would cost” (DOHb, 2011). The main benefit of the scheme is that it gives patients control and choice over how the money is spent. This increased involvement has a number of advantages, not just for the service but also for the patient; “It can have a huge impact on mental or psychological health and I think that it will have an impact on keeping people healthy rather than this kind of dependency that people can get when they sit back and aren’t involved [in their care]. Giving them [the budget holder] the control and making them the person managing their health rather than being managed is quite a big win here” (PHBE, PSSRU and University of Kent, 2010). As previously identified, the intangibility of health care acts as a contributing factor for patient confusion around value. As a solution Lovelock and Wirtz, suggest using ‘vivid information’, to produce for users, a ‘strong, clear impression on the senses, especially for services that are complex and highly intangible’. (2004)

Background

The result of this information void is that patients look for cues to understand value; ‘heart surgery patients try to learn more about which doctors have good reputation, which procedures have the highest success rate and which hospitals provide the best recovery care. Still, most patients would admit that they really don’t have much idea just how good their doctor is’. (Harford, 2007, p.128) High levels of dissatisfaction with NHS Dentist services were reported within a survey conducted by Ipsos Mori in 2008, revealing that patients often could not judge the quality of their Dentist until visiting the practice (Ipsos Mori, 2008). The kinds of things that were most valued by patients included clear explanations of treatments, time taken by the staff and Dentist, pain management, qualifications and a clean and comfortable environment. It was suggested that ‘star ratings’ could help to communicate these aspects (Ipsos Mori, 2008). There is a clear patient need for assistance when judging the value or quality of care as well as a desire for control over personal health information. A number of websites currently exist to allow patients to create their own online health records (NHS Healthspace, Microsoft’s Healthvault and howareyou.com), but require a considerable amount of pro-active behaviour. The NHS White Paper, ‘Equity and excellence: Liberating the NHS’, sets out the Government’s long-term vision for the future of the NHS; including a ‘patient focused’ approach to information, so called ‘The Information Revolution’. The ‘Information Revolution’, attempts to give ‘people more information and control and greater choice about their care. The information revolution is about transforming the way information is accessed, collected, analysed, and used so that people are at the heart of health and adult social care services’ (DOH, 2011c) If the NHS aims to be truly transparent with patients, there is an opportunity to create understanding of what the service is delivering for users. Sensitising patients to the value received has the potential to increase satisfaction and highlight areas for service improvement.

Background

MAKE INFORMATION RELEVANT

CONSIDER THE CONTEXT

Communicating costs to patients as generic price lists does not reflect how people feel about or use the service. In order for the information to be cogent and have impact, it must be relevant.

Consideration of where, why and how the intervention takes place is vital to determine a patients response to information. Three examples where information discloser has failed to alter behaviours and perceptions, include the McDonalds Calorie Counter (Davies, 2011), Act on Co2 (Science and Technology Select Committee, 2011) and US tax receipts (Kendall and Porter, 2011).

With increasing popularity of using behavioural economics approaches by government, bodies such as The Behavioural Insight Team have been set up to tackle issues within public health, energy efficiency and climate change as well as others of similar magnitude (Cabinet Office Behavioural Insights Team, 2011). The government research charity, The Institute for Government, has published a paper entitled ‘MINDSPACE: Influencing behaviour through public policy’. Within this, they explore the applications of behavioural theory within public policy, creating a neat checklist for influence; Messenger, Incentives, Norms, Defaults, Salience, Priming, Affect, Commitments and Ego (Institute for Government, 2010). The emphasis on salient information is one that bears particular relevance to the project. The report states that, ‘our attention is drawn to what is novel and seems relevant to us... In our everyday lives, we are bombarded with stimuli. As a result, we tend to unconsciously filter out much information as a coping strategy. People are more likely to register stimuli that are novel (messages in flashing lights), accessible (items on sale next to checkouts) and simple (a snappy slogan). Simplicity is important here because our attention is much more likely to be drawn to things that we can understand – to those things that we can easily ‘encode’’ (Institute for Government, 2010). This advises that messages must be coherent, positive, tangible and most of all, relevant to the reader, or it risks losing audience interest.

As part of the government’s “responsibility deal” the fast food chain McDonalds have recently included calorie information for customers alongside their menu items. However, company research indicated that ‘...among 2,000 of its customers, fewer than one in five – 17% – said that calorie information would make them think more about what they were eating’ (Davies, 2011). A government campaign called ‘Act on CO2’ attempted to persuade individuals to reduce their carbon footprint. The Sustainable Development Commission blamed the campaign for ‘failing to communicate effectively with the public, for being too negative in its messages, and for not including any supporting interventions to address the barriers to adopting low carbon behaviours’ (Science and Technology Select Committee, House of Lords, 2011). A trial was conducted to correct inaccurate assumptions of federal government spending of tax; a large proportion dramatically overestimating spending on foreign aid. Despite giving taxpayers a breakdown of spending, the difference was negligible between answers of those shown receipts and those not, to questions about perceptions of wastage and spending (Sides, 2011). David B. Kendall and Ethan Porter comment within the Washington Post, that ‘a taxpayer receipt won’t reduce anyone’s tax burden. But it might reduce the burden of paying taxes’. They call this the “identifiable victim effect,” a concept that holds that knowing more about where your money goes increases your satisfaction about spending it’ (2011). This theory provides strong support for the project; the focus is not to correct patient perceptions of cost or getting people to think twice about using the service, but rather to create a sense of value.

Background

MESSAGE AND LANGUAGE Due to the sensitive nature of communication between the NHS and its patients, the tone and form should meet a number of requirements. Remain within current NHS branding guidelines. Clarity and consistency throughout. Representing figures and data in accessible formats, ie. nothing too technical or potentially unfamiliar. It may be appropriate to use recognisable formats, such as those used on food packaging or energy bills. Brief enough to peak interest without overwhelming the reader with too much information. Using the word ‘free’ sparingly to create a sense of a ‘good deal’. As Dan Ariely points out; ‘... we can use FREE! to drive social policy... if health is your concern, focus on early detection as a way to eliminate the progression of severe illness... Make these critical procedures FREE!’ (Ariely, 2009, p.62-63). The key benefit of the NHS is that it covers costs so patients don’t have to worry if they fall ill. Similar to insurance, the health service provides a ‘safety net’ for patients. Focusing on this underlying concept communicates a positive message. The tone should be neutral; patients don’t want to be told off, further enforcing the ‘us and them’ mentality. The facts need to be presented within a wider context rather than just focusing on the individual alone, to give a sense of relativity. The content needs to strike a balance between the needs of the patients and the interests of the service.

Background

Contextualising your energy usage Source: http://www.maxgladwell.com

BUPA outlining for patients what to expect for their money

BUPA statement, showing theirs/patient contributions

EXISTING WORK There have been a number of different studies and suggestions, exploring the notion of communicating costs to patients. Most notably, a Yorkshire PCT, told patients how much treatments cost. Karen Knapton, NHS East Riding of Yorkshire chair, explained, “This is about promoting awareness of costs, and highlighting some of the unnecessary admissions to hospitals... a lot of people are surprised when they see the figures. They expect to have the right to have treatment, and successful operations, but don’t think beyond that…” (Health Service Journal, 2010). A paper published by think tank The Kings Fund, suggests publishing costs of prescription drugs as a means of improving medication compliance, stating ‘it is also possible that drug wastage by patients would be less if the costs of medication supplied were made explicit. Consideration should be given to research to see if medication adherence can be improved by labelling prescriptions with the cost to the NHS’ (2011). Highlighting the fine balance of this project, GPC prescribing subcommittee chairman Dr Bill Beeby raised some concerns saying that ‘...the relatively low price of some drugs would make patients question their value. Also, the high cost of some drugs might deter some patients, such as the elderly, from taking them’ (Moberly, 2011). These are valid comments which suggest that information needs to be contextualised to give patients the complete picture when looking at costs. A paper from think tank 2020 Health, suggested issuing costing disharge summaries to patients upon leaving hospital (Manning, Hill and Beer, 2010). In a separate paper by the same think tank, when discussing the charging of patients for prescription items, the group state that ‘there is evidence in many fields to suggest that if people are not involved in a commercial transaction and are under the impression that they are getting something ‘for free’, then the item obtained is valued less’ (Roche, 2008). The concept of communicating costs doesn’t appear to have been extensively trialed to date, yet the circulation of the idea is encouraging.

NHS downplaying free flu jabs for those at risk groups

Background

Co - Insight

THE SESSIONS

THE PARTICIPANTS

The sessions were organised as a means of understanding patient experience; these could be described as ‘co-insight’. Rather than ‘co-design’ where users aid the design as well as research processes, these sessions were primarily focused around finding insight.

The participants consisted of a mixture of family and friends, ranging in age from 26 to 81 years old. The advantage of conducting the sessions in informal settings, with familiar faces meant the project benefited from insight of genuine patient experience; something that may have proved more difficult if speaking with strangers.

The sessions were either carried out on a one-to-one basis or in group discussions. Group sizes ranged from 3 - 15 and were divided into age segments so that similarities between patients due to age meant the more personal information might be easier to share. The term ‘value’ could be interpreted in many ways, with subtle differences resulting in completely different understandings. It was necessary for each participant to express and come to their own definition of what value meant for them within different service contexts other than just health.

For best results, the sessions required different types of service user to be consulted in order to gain the broadest overview. Fortunately, it was possible to involve a small number of people with long term health conditions as well as those who were generally in good health. It was ensured that each person was informed of their role in the project, and where personal information was shared, assured that anonymity would be maintained throughout.

Because of this, the focus was on conversations of how value is perceived rather than how they might begin to come up with solutions themselves. The variety of methods will be discussed in more detail shortly along with the results of the exercises and conclusions where possible.

Co-insight

QUESTIONNAIRES

PROFILES

Two short questionnaires were first completed by the participants in order to gauge each patients level of service use.

Information covering, age, occupation, state of health, long term conditions, service usage levels and health lifestyles of each codesign participant.

They also gave opportunity to offer a small description of their personal state of health and attitudes towards diet and lifestyle. These questionnaires formed a set of patient profiles (see opposite pages) acting as brief summaries to contextualise responses to further exercises. See appendix item: B

Copies of the questionnaire can be found in the appendix.

At the top of each profile, there is a summary of each persons service usage levels. The number of times that they use the service throughout the year is ranked as below: Times used per year:

Rating:

Very low

1-3

Low

3-6

Medium

6-10

Medium-high

10-15

High

15+

Very high

This has been done, in order to try to highlight which services are being used the most, as well as the kinds of patients that use one service more than another.

Co-insight

PROFILE 1 Health statement

PROFILE 2 Suffered with a number of health conditions following an accident, causing spinal injuries.

Health statement

Mainly housebound and unable to engage in any exercise due to physical limitations, therefore it is important to eat as healthily as possible.

Previously treated for Cancer and receives supplies for self care as well as unrelated presciptions that are exempt from charges as a result.

Taking a high number of different medications to control the variety of problems.

Cares for spouse (A).

Despite feelings of frustration associated with limited capabilities, remains with a positive attitude.

Summary

Services used (most)

Rating

GP Pharmacy Outpatient elective care (rare)

Medium Medium Low

Age

Occupation

Out of work due to health

State of health

Poor

Conditions

Long term conditions following a car accident Damage to cervical vertebrae and compaction High blood pressure Poor circulation Water retention Nerve damage IBS Tinnitus and migraines Trigeminal neuralgia

Generally in good state of health. Doesnâ&#x20AC;&#x2122;t smoke, (or take drugs!) and has a low alcohol consumption.

Provides sole financial support for family. Has two children, both in full time higher education. Time restrictions make exercise difficult to fit in, although walks for half an hour during lunch breaks most days and enjoys gardening during any spare time. Has a mammogram once every three years. Summary

Services used (most)

Rating

NHS Direct GP Pharmacy (not personally)

Medium Low/very low Medium

Age

Occupation

Credit controller

State of health

Good

Conditions

Currently being treated for torn knee ligament and Osteoarthritis

PROFILE 3 Health statement

PROFILE 4 I work on an allotment (full size) which keeps me fit, so I get a lot of exercise.

Health statement

As for food, don’t have any allergies as far as I know, so would say that I enjoy my food.

Try to have a balanced diet and buy good quality food. However too indulgent with some things. Know I need to lose weight.

Alcohol consumption moderate.

Alcohol consumption is on the recommended limit.

Used to smoke but haven’t for 26 years.

Summary

Services used (most)

Rating

Low

Have never smoked. Think my health is generally good but that I should do more to protect it, eg. lose weight, take more exercise.’ Summary

Age

Occupation

Retired

State of health

Good

Conditions

Treated for high blood pressure

‘Try to go for a walk each week - at least once. Pilates for flexibility and core muscle strength. Should do more!

Services used (most)

Rating

GP Pharmacy

Low Medium

Age

Occupation

Teacher

State of health

Good

Conditions

Mild asthma

PROFILE 5 Health statement

PROFILE 6 ‘Try to keep reasonably fit. Exercise regularly. Walk/cycle regularly.

Health statement

Smoke but stopped around 30 years ago. Check weight weekly (but need to lose some) Drink less than half recommended alcohol intake.’ Summary

Services used (most)

Rating

Pharmacy GP

Very low Very low

Age

Occupation

Chartered Engineer

State of health

Good

Conditions

None

“Diet: My diet is pretty good, I generally eat a fair balance of food and not too much of anything and don’t eat lots of crap. I don’t think at all about what I eat and only eat a balanced range because that’s the food I like eating. I’m aware I should eat more fruit but I don’t. Exercise: I’m a bit lazy and poor, I’m currently trying to do more but will probably not do a huge amount as it gets colder. I think I would feel healthier and happier if I did more exercise. Alcohol: I occasionally (with decreasing regularity) drink too much. I like to drink wine but rarely more than a few glasses in an evening. I have a pretty low alcohol tolerance, I don’t know if this is a good thing because it means I drink less or a bad thing because the alcohol I drink affects me more.”

Summary

Services used (most)

Rating

GP Pharmacy Other

Low Low Very low

Age

Occupation

Graphic Designer

State of health

Good

Conditions

None 39

PROFILE 7 Health statement

PROFILE 8 “Exercise twice a week and walk where I can.

Health statement

“Play football twice a week and very occasionally run or cycle. I eat relatively healthily, but do adapt my diet based on how active my Crohn’s Disease is.”

Summary

Services used (most)

Rating

GP Outpatient elective care Dentist, Pharmacy, NHS Direct

High Low Low

Try to eat a healthy, balanced diet, with plenty of fruit and veg.” Mother of two children - 2 and 4 years old

Summary

Services used (most)

Rating

GP NHS Direct

Medium Medium Age

Occupation

IT Manager

State of health

Good generally

Conditions

Age

Occupation

HR Admin

State of health

Good

Crohn’s Disease Kidney stone (past 4 years)

Conditions

None

Is treated privately as well as under the NHS

USER JOURNEY MAPPING

Details:

The first session began by asking each participant to describe a recent interaction they had had with the NHS. This interaction is termed a â&#x20AC;&#x2DC;user journeyâ&#x20AC;&#x2122; whereby it is possible to trace the patients actions as they move through the service over a period of time. The template sheet had four columns: Action (what happened)

Date of user journey:

Things/media/devices (that they interacted with) Feelings Passive-Active (plotting on a line how passive or active they felt in their care at that point in time) The intention was to see if there was any correlation between what was happening at the time, how a patient was feeling, and whether that had any relationship to how active or passive they felt.

Feelings

Things / media / devices

Actions 42

Passive - Active

Service user journey map

Name:

The sheet also made it possible to illustrate where an intervention might take place within the patient journey.

User journey mapping

Co-insight

VALUE WITHIN SERVICES Printed onto cards, were statements about different aspects of general services. This exercise asked people to think about which aspects of a service they valued the most. The cards were to be ordered from most to least valued. The results from this exercise were averaged as follows: Most valued (joint)

Past experience How successful has the service been before? Outcomes How well does it meet your needs? Price How much does it cost? Personalisation Are you treated as an individual? Convenience How easy is it to use?

Least valued

See appendix item: C

Word of Mouth What do others tell you about it?

The full results can be seen in the appendix.

Co-insight

Service aspect cards

VALUE WITHIN THE HEALTH SERVICE The next exercise followed a similar pattern, however printed on these cards, were statements about different aspects of the NHS service/health care service. The categories are general statements that cover different aspects of health care. Once that had been completed, the individuals were also asked where, if they had to pay for the health service, would they place cost - ie. how much would price be a deciding factor in your health care? Again, the participants were asked to order the cards/aspects from least to most valued:

See appendix item: D

Most valued

Effective treatment and successful outcomes

(joint)

Continuity of care Seeing the same Doctor, co-ordination of care... â&#x20AC;&#x2DC;Costâ&#x20AC;&#x2122; was placed the most times here

(joint)

Manner of staff and Physician Trustworthiness, friendly... Choice and range of services available

(joint)

Participation + representation in decision making Comprehensive information Service provision, health advice... Convenience and ease of access of services Opening hours, physical access...

Least valued

Physical environment and surroundings Building, furnishings...

The full results can be seen in the appendix.

Co-insight

Health service aspects cards

GUESSING THE COSTS OF SERVICES Through the use of cards, participants were asked to guess roughly how much certain services cost. The following services were the given examples: TV License fee - colour television Hair cut - womens, wet dry and cut, reputable chain hairdressers Restaurant dinner - 2-3 courses, glass of wine, chain, high street restaurant Cinema ticket - one adult ticket, local chain cinema Flight from London to New York city - return flight Full vehicle service and MOT University fees - per year, full time undergraduate, 2011 fees The chosen services were everyday and easy to recognise, so that participants could make informed guesses based on experience. This exercise was designed with the purpose of seeing how accurately people could guess, based on their own sets of â&#x20AC;&#x2DC;reference costsâ&#x20AC;&#x2122;. This provided a fair comparison with the next exercise. Online research to calculate average prices was carried out on each of the services. The results were judged to be underestimated or overestimated if the guess was 20% outside the correct amount. See appendix item: E

The full results can be seen in the appendix.

Co-insight

Guessing the costs - services

RESULTS What were people overestimating the cost of? Flight from London to New York City If one does not fly frequently, they would not be expected to know the cost of a long haul flight; equally if they have not flown recently, it would be difficult to predict accurately how prices have changed. What were people underestimating the cost of? Hair cut University fees The instances where the price of a womens hair cut was underestimated, were made by men, suggesting that judgements may have been skewed by their own reference costs (with male haircuts being generally cheaper than females). These are speculations as to why peoples guesses have fallen above or below the true costs.

Guessing the costs - services

Co-insight

GUESSING THE COSTS OF TREATMENTS Participants were asked to guess roughly how much NHS treatments and procedures cost the service to deliver. The following treatments were the given examples: Appendectomy - removal of the appendix, in patient hospital stay Hip fracture Blood test Ultrasound scan - lasting 20 minutes+ Lung transplant Tonsillectomy - removal of the tonsils, in patient hospital stay MRI scan - magnetic resonance imaging scan The costs for these treatments and procedures are based on amounts published by and for the Department of Health Costs (DOH, 2009-10) were coded and not designed for public reference. For this reason it was not possible to state to what degree of care the costs covered, for example whether the hip fracture would include aftercare. This test serves as an interesting comparison to the previous exercise which looked at accuracy around known services. The results were again judged to be underestimated or overestimated if the guess was 20% outside the correct amount. See appendix item: F

The full results can be seen in the appendix.

Co-insight

Guessing the costs - treatments

RESULTS What were people overestimating the cost of? Blood test MRI Scan What were people underestimating the cost of? Hip fracture Lung transplant Appendectomy It is possible that there is some relationship between peoples understanding of what is involved with such procedures and guessed cost. It is unlikely that someone would know the details of what would be involved in a lung transplant, however, a blood test is something that most have experienced. For this reason, people may have overestimated or underestimated the price based on a good or lacking knowledge of the treatment. Again, these are speculative suggestions for such results.

Guessing the costs - treatments

Co-insight

How much income tax you pay? Least accurate guess

Your vehicles mileage per gallon?

Unsurprisingly, it appears the greatest awareness lies around consumption of money - income, expenditures etc. It could be argued that although energy bills are high on the list, people are more concerned with the implications of excessive energy usage being an expensive bill at the end of the month.

Co-insight

Hardly ever

No idea I could guess Consumption questionnaire

What your bank account balance is? How much income tax you pay? What your average shopping bill is? What your vehicle mileage is? How much petrol you have left? Your vehicles mileage per gallon?

What your bank account balance is? What your average shopping bill is? What your vehicle mileage is? How much petrol you have left?

Do you know (without checking):

Most accurate guess

Almost exactly

Do you know (without checking)...

Bank statements? Receipts? Pay cheques? Student loan? Energy bills / statements? Phone bills? Own weight? Fat/sugar/salt content of food?

Least checked

Bank statements and pay cheques Energy bills Phone bills Fat/sugar/salt content of food Own weight Receipts Student loan

Very often

Most checked

How often do you check your:

How often do you check your...?

Not that often

This exercise was designed to help judge peopleâ&#x20AC;&#x2122;s awareness when it comes to their own consumption; for example how much money they spend, how much energy they consume, how much petrol they are using and so on. The results were as follows:

Quite often

CONSCIOUS OF CONSUMPTION?

DRAWING VALUE In order to encourage discussion around notions of value, participants were asked to ‘visually communicate value’ by drawing their own interpretation of what value for money means to them. Please see opposite for these drawings. Image one “This is me shopping. The place that I am going to buy my shopping, it has the food that I like, especially, at the price that I like. And on the way there, it makes me feel special, by giving me a red carpet and opening the door for me. They do things that make me feel valued to be there” Image two “To get good value you have to pay a certain price for it. Spending the right money to get the right goods.” Image three “In industry, you have your inputs, you have your outputs. What happens between the two is the value for money… if you can come up with a system where you don’t have to contribute a lot, but get a lot back, then that must be value for money.” Image four “I’ve got a table with two people, one at each end, and it’s a question of give and take” Image five “Each of my blocks has got a pound sign opposite of it… the theory is that… assuming everybody is paying the same amount of tax every year, when you’re young and say single, you get back relatively little in exchange for your pound. But then, as you get older, you get more and more back for your pounds…”

Co-insight

Image one

DISCUSSING VALUE See appendix item: G

Four group sessions were held with discussions around â&#x20AC;&#x2DC;valueâ&#x20AC;&#x2122;; these were recorded as audio files. Below are a selection of quotes taken from these sessions; complete transcripts can be found in the appendix. A number of points stood out from the discussion as interesting and useful insights into perception of price, services and the health care system. Defining what you want as a consumer/user/patient It was mentioned that it would be possible to say whether a good service had been received or if one was satisfied, only if as a user, you understood exactly what was required or desired. This suggests that interventions may not only inform what is received but also set a level of patient expectation. Trust Spoken about with relation to car maintenance, the issue of trust was raised a number of times throughout one of the sessions. Trust is a fundamental part of a patient experience; something that can be improved through transparency of information especially around specialist topics. No need to worry about cost One of the key comments that was made, was that the National Health Service essentially provides a fall back option without the worry of cost. Illness is unpredictable, therefore knowing the service is designed to treat (mostly) regardless of cost can take a huge burden off the mind of a patient.

Co-insight

Discussion

FEEDBACK ON INITIAL PROTOTYPES A number of different prototypes were mocked up to get an idea of initial reactions to some of the information presented. These took the form of receipts, statements and phone messages informing patients of the cost of their care.

NHS

Your total balance this year is £210.45. Thank you for choosing the NHS.

NHS Please call to book your blood test. The NHS will cover the charge of £4.00. Thank you for choosing the NHS.

This also allowed participants to begin thinking about the possibilities for the project outcome; instead of just focusing on abstract notions of value they were able to offer some feedback using tangible mock-ups. This exercise in particular provided some very useful insight into how patients would interpret the information. Some were designed to be intentionally provocative to test reactions, however generally there were a range of different opinions. See appendix item: H

The following key points were made within the feedback, complete transcripts can be found in the appendix. Don’t use the word ‘choose’ The sentence ‘Thank you for choosing the NHS’ has been printed to gauge the level of reaction; it became quite clear that the word ‘choose’ should not be included because patients felt that they had not made a choice. The word ‘using’ was much more acceptable. Interval of message An important issue was raised on how often the intervention should have contact with the patient. It was suggested that too often would result in patient resentment as it almost becomes a ‘nagging’ piece of communication.

Hermitage Surgery Visit 14/03/11 Appointment Blood test Aspirin

£25.00 £4.00 £4.50

Total

£33.50

Your NHS yearly statement Jan 2011 - Jan 2012

Total tax contributions Total service usage

£1,394 £389

Total tax contributions Total service usage

Last years usage

£5,987

78% of patients, your age, have a lower blood pressure than you.

Thank you for using the

According to our records, you are due a check-up. Please call to book yourself an appointment.

Your NHS yearly statement January:

Representing the GP As the GP acts as gatekeeper to most NHS services, the information should strike a balance between representing their decisions and the value they deliver as well as highlighting how the patient benefits. Through the feedback, it is apparent that the information needs to appeal to patient self-interest rather than ‘preach’ from a service provider perspective.

3 medical professionals

Pathology

Total

Reduce yours by 5% 10 minutes of exercise a day Don’t add salt when cooking A glass of fruit juice a day

Your NHS yearly statement Jan 2011 - Jan 2012

Blood test Urine test Ultrasound GP appointment X-ray Bucastem 3mg

34 minutes

£80

£1,394 £4,589

Total

x1 x1 x1 x8 x1 x6

£4 £4 £69 £200 £2 £4

£283

Thank you for choosing the NHS February:

Co-insight

Initial prototypes

Outcomes

DEVELOPING THE OUTCOMES To test the hypothesis of this project, the scope needed to be focused down from a general approach that could be applied to every type of patient at every stage of their service interaction, to something more manageable and therefore â&#x20AC;&#x2DC;testableâ&#x20AC;&#x2122;. For this reason, the project has resulted in two outcomes; one looking at primary care, primarily GP visits, the other addresses newly diagnosed diabetic patients. This meant that both prototypes could include fairly routine examples of care, restricted to that specific type of encounter or patient.

Bringing together the project research and insights, two key criteria were created:

During prior discussions with Professor Daniel Streenstra (Cranfield University) and Jane Tinkler (London School of Economics, Public Policy Group Manager), both encouraged designing an intervention around the diabetes care plan due to its predictability. This suggestion was developed to form a contrast with the more general primary care prototype. The idea that these interventions would only communicate cost was dismissed at an early stage. As Dr Beeby identified earlier in the report (Moberly, 2011), sensitising patients to the monetary aspects devalues the nonmonetary service qualities that patients find most important. As a solution, patients should be able to see both the costs of what they receive as well as the value, integrating the two. The co-insight sessions highlighted the most valued service elements, when seeing their GP or going to hospital. Although outcomes and recovery held priority for most, it was the other aspects, such as being able to see your Doctor when making appointments, or being given the time by medical staff to explain treatment properly that people found to be most important.

Outcomes

The outcomes should add value to the patient experience The intervention needs to be useful to the patient, adding value to their experience instead of burdening it with additional irrelevant information.

The content needs to integrate value as well as cost data The information content, should not just focus on cost alone. Each time a patient is informed of how much they have used the service or how much treatments cost, they should also be shown the level of care they are receiving for the money that they contribute.

Outcomes

PROJECT BRIEFS Primary care prototype

Diabetes prototype

Around 90% of all patient contact with the NHS, takes places within primary care (DOH, 2011d), with general practices seeing patients an average of 5.5 times a year for consultations (The NHS Information Centre, 2009).

The Diabetic Care plan, usually routine, consists of a number of checks and consultations with specialists throughout the year depending on the condition of the patient. Within the document ‘Diabetes – what care you should receive’ (Diabetes UK, n.d.) is a 15 point check-list for patients to understand what care they are entitled to throughout the year. These include things such as (Diabetes UK, n.d.):

As the majority of people will be seeing their GP or using at least one primary care service during the year, by introducing usage information and the idea of cost at this point, the tone is being established early in the process for any further treatments within the service. Furthermore, by excluding acute care, this intervention concentrates on preventative medicine rather than the treatment of serious illness. Although slightly more complex, there is the potential for additional service data, such as A&E where, as this report has identified, there is a considerable amount of avoidable waste that takes place. This has not been included within the prototype as the approach for addressing these kinds of issues would reach beyond the limits of the project.

- - - - - - -

Blood glucose levels measured Blood pressure measured Blood fats (cholesterol) measured Eyes checked Legs and feet checked Kidney functions monitored Weight checked

There are additional services available if patients are planning for a family or wish to give up smoking. The checks take place throughout the year and make up a large proportion of the patients preventative care plan. Patients living with other long term health conditions would no doubt have similar ‘plans’ to help with managing their health, therefore the potential is that an intervention for those with diabetes could be applied to include a wider remit of patients. Despite plans and cost exemptions for such patients, only one third of people in at risk groups, are reportedly taking up their offer of a free flu jab (Press Association, 2011). This has potentially serious health implications for patients and cost implications for the service. Through communicating the value (reducing the risk of illness) for the price (free) to patients, it may be possible to increase uptake for these services. With the NHS spending 10% of its yearly budget on diabetes and associated complications alone (Gould, 2011) reducing risks remains high priority.

Outcomes

INITIAL IDEAS These initial ideas are based upon the two criteria stating that: 1. The outcomes should add value to the patient experience 2. The content needs to integrate value as well as cost data

Activity log A smart phone application that asks patients to log their interactions with the NHS upon leaving the Doctors, Pharmacy etc. Logged activity is collected and accessed by the patient through an online platform, creating a personal patient record.

MBA/MDES COLLABORATION 2011

Which services did you use today? >

Alternatively a book may be stamped at each interaction point, detailing where, when and who the interaction was with. This then becomes a record for the patient to track their activity. Problems: The artificial scarcity and inconvenience of tokens doesn’t promote transparency and ease of use for patients.

Problems: This solution requires far too much pro-active behaviour from the patient with reward only for those curious enough to want to track their own activity.

Instead patients may become more suspicious and distressed by the threat of limited access to health care, which would not be the case.

Swipe card Similar to the previous concept, to make the interaction more seamless, a card could be swiped at each location automatically logging activity.

Tokens/stamped book Tokens are exchanged for health treatment, creating a ‘transaction like’ relationship whilst giving the impression of scarcity. Tim Harford points out that scarce supplies hold inherently more value than those in abundance (2007).

Annual Statement Issued once a year, the statement would detail all patient interactions throughout the past 12 months. This could include general data such as national averages to contextualise personal data.

Outcomes

lth l hea nnua 11_ a r u Yo 20 m e nt s t a te 8 e nt s intm o p p fa t No. o tm en p p o in a P 3 G 5.0 0 22 / 0 £4

OUTCOME ONE PERSONAL ANNUAL HEALTH REPORT Predicted health spend At the beginning of the year, patients predict how much they think their health care will cost the NHS ‘this year’. Each time they use the service, the actual cost is deducted from that amount.

MBA/MDES COLLABORATION 2011

Predicted health spend 2012 £300

This asks patients to set their expectation for the year in something perhaps more light hearted than some of the other ideas.

The Personal Annual Health Report takes the form of a physical or electronic booklet that is sent to patients once a year. The contents show patients how they have used Primary Care Services over the past 12 months. Costing and usage data is paired up with information that explains the value of the service. This better informs patients on how the service is spending their money to meet their needs. The reports also act as mini personal health records, which if collected together, can allow patients to track their health over a period of time. The information has been carefully selected to highlight service aspects that co-insight participants felt to be important, such as continuity of care and information on the choice of services available.

Problems: There is a high chance that patients would be antagonised by something that seems to punish them for using the service. There is a negativity around the usage exceeding the guess, as the patient ‘loses’ the game.

All of the content is divided into two types - personal (orange) and general (blue) data. Integrating general and personal data means that patients are presented with information relevant to them as well as contextual data to give an overview of their position within the entire service.

Successful elements from some of these ideas have been taken forward to form the basis for the final outcomes.

The report reveals levels of information in stages, beginning with a broad set of data about the NHS in general, working towards more specific data about the patients general practice through to the patient themselves. This guides the reader through the information, instead of publishing costs at the start which would seem confrontational. The highly detailed content is placed at the end as an in depth look at patient usage, whereas the other information is presented as short, snapshots of data covering a range of aspects. Visually, the outcome adheres to NHS branding guidelines (NHS Identity, 2011), using the typeface and main colour throughout.

Outcomes

OUTCOME ONE SERVICE PROCESS The diagram below describes how the data collection part of the intervention would work in relation to the patient journey. The patients actions are on the left (what the patient does) and the service actions are on the right (how the service reacts).

Patient actions

Service actions

Visit to GP

Data logged

Reports received

Data processed

Personal Annual Health Report Prototype

As the patient visits primary care services throughout the year, the data is logged in a central system. Much of this data already exists within patient records while the more general information is published online within â&#x20AC;&#x2DC;Health Services near youâ&#x20AC;&#x2122; on the NHS site.

Outcomes

Health Reports

National Health Service

Every NHS Patient receives a Health Report once a year, detailing how you have used Primary Care Services over the past 12 months.

The NHS was born out of a long-held ideal that good health care should be available to all, regardless of wealth.

Primary Care Services are your first point of contact with the NHS and include things such as General Practices, Dentists, Opticians, Pharmacies, Walk-in-Centres and many more.

Funded by you and 52 million others, the NHS provides care when you need it the most; leaving you free from the worry of cost. With the exception of charges for some prescriptions and optical and dental services, the NHS remains free at the point of use.

Around 90% of people’s contact with the NHS is within Primary Care

The Report also serves as a personal record of your health, including a ‘calendar’ that shows when and with whom you’ve have a GP appointment, along with a record of any prescription items that you have been provided with.

Around 3 million people are treated in the NHS in England each week

You + your care

This happens every day:

Name NHS no.

Mr Thomas Goulding 943-476-5919

Dr Andrew Sibson

Practice details

Yorkshire Street Medical Centre 80 Yorkshire Street Burnley Lancashire BB11 3BT

NHS eye tests

Pharmacies serve

31,000

1.2 million

for health related reasons

01282 420141 NHS Dentists treat

GPâ&#x20AC;&#x2122;s and Practice Nurses see

250,000

800,000

Monday-Friday 08:00-16:30 Saturday and Sunday Closed

Which Primary Care Services have you used this year?

Most visited Primary Care Services in your area

Quest Dental Care

1st

2nd

3rd

4th

Vision Call Yorkshire

Burnley GUM Clinic

Yorkshire Street Medical Centre Alliance Pharmacy East Lancashire Stop Smoking Service

Alliance Pharmacy

1 2 3

Yorkshire Street Medical Centre

Our records show that you have used the following Primary Care Services this year:

5th

About your General Practice

Yorkshire Street Medical Centre has 1803 patients

Services available at Yorkshire Street Medical Centre Family Planning Clinic Antenatal Clinic Baby Clinic Mother and Baby Clinic Child Development Asthma Clinic Chronic Obstructive Pulmonary Disease Diabetes Clinic Dietician HCA Clinic Heart Disease Travel Health Well Woman Clinic Well Man Clinic

Practice Nurse team

Dr Mark Walton

Dr Paul Hartley

468 patients

324 patients

Dr Hasna Begum

Dr Andrew Sibson

144 patients Dr Naomi Hemsley

540 patients

216 patients

About your GP

How often do you get to see your registered GP when you make an appointment?

Dr Andrew Sibson 72% of your appointments have been with your GP

Your GP 8 appointments this year

Dr Paul Hartley 2 appointments this year Your registration date

Experience

22/04/02

10 years

Worked at Yorkshire Street Medical Centre

Specialisms

5 years

Dermatology Diabetes

Dr Naomi Hemsley 1 appointment this year

82% of patients at Yorkshire Street Medical Centre are able to make an appointment with their preferred Doctor

How many appointments have you had?

When do you make most of your visits to your GP?

Appointments 2011

Time of day

Day of the week

16:30-18:30

Monday

Your appointments typically fall between these hours

You had 5 appointments on a Monday in 2011

6 attended 2 missed

If you think you might miss an appointment please ring 01282 420141 to re-schedule

Yorkshire Street Medical Centre is most busy during the months of December and January on a Monday at 08:30 and 17:30

6 appointments 째 4 째

5 째 2 째

2011

2010

2009

2008

Your Report in detail 2011

Date

Where

With

Description

Average cost

NHS cost coverage

22/03/11

Yorkshire Street Medical Centre

Dr Andrew Sibson

5 minute appointment

£15.00

Full

23/03/11

Pharmacy

Ampicillin 250mg capsules Penicillin

£6.36

Part

15/06/11

Yorkshire Street Medical Centre

Dr Andrew Sibson

15 minute appointment

£45.00

Full

26/08/11

Yorkshire Street Medical Centre

Dr Andrew Sibson

15 minute appointment

£45.00

Full

26/08/11

Pharmacy

Enalapril 2.5mg Hypertension

£1.07

Part

02/10/11

Yorkshire Street Medical Centre

Dr Andrew Sibson

15 minute appointment

£45.00

Full

11/10/11

East Lancashire Stop Smoking Service

Rishton Health Centre

1 hour group session

£59.28

Full

Your prescriptions 2011

Date

Item

Cost

You pay Pre-paid certificates

23/03/11

Ampicillin 250mg capsules Penicillin

£6.36

£7.40

26/08/11

Enalapril 2.5mg Hypertension

£1.07

£7.40

26/12/11

Varenicline 12 week course Nicotine cravings

£163.80

£7.40

From 1 April 2010 a three monthly PPC is £29.10. This saves you money if you need four or more items in three months. A 12 month certificate is £104.00 and saves money if 15 or more items are needed in 12 months.

Your recommended health plan for 2012

Recommendation

Description

Where

Average cost

NHS cost coverage

Blood pressure check

As you have been prescribed Enalapril for high blood pressure, it is advised that you have regular checks

Yorkshire Street Medical Centre

£15.00

Full

Bowel screening

Men and women over the age of 65 continue to be offered bowel cancer screening in the form of a faecal occult blood testing (FOBT) kit in the post every two years until the age of 70

By post

£5.00

Full

Urinalysis

This is a test involving a strip that, when dipped in urine, can reveal a number of conditions including diabetes

Yorkshire Street Medical Centre

£37.00

Full

OUTCOME ONE SERVICE DESCRIPTION The images on the previous pages show each spread of the booklet; a breakdown of page content is as follows: Health Reports The opening page informs the patient as to why they are receiving the report and how it could benefit them. It’s important for patients to understand the reason for the report as it opens an entirely new conversation between themselves and the service. National Health Service One of the main benefits of tax funded services such as the NHS, is care provision when it’s most needed, without the worry of cost. This sets the tone for the report, stating the underlying value for money unique to public services. This happens everyday: An overview of the service to show the breadth and volume of service users treated everyday. Because patients dip in and out of parts of the service, it may be easy to forget the size of the system. You + your care Your own personal patient data, along with details of your general practice for quick reference. This provides readers with something physical to quickly check in order to contact their general practice. It also introduces the first piece of personalised information, letting them know that each report is unique to each patient. Which Primary Care Services have you used this year? Reminding patients of the services that they have used over the past 12 months. Most visited Primary Care Services in your area Giving patients an overview of how they are using services in relation to other people. This gives context and allows patients to see the extent to which services are used locally.

Outcomes

About your General Practice This spread shows the range of services available which was something that was highlighted in the co-insight sessions. The breakdown of patient numbers allows patients to see how they ‘fit’ into a wider picture. It also serves to manage patient expectation if they are not always able to see their GP when making appointments. About your GP Communicating the value that is received each time you see your GP; giving patients some background on their GP shows a range of aspects of the quality of care received. How often do you get to see your registered GP when you make an appointment? Importance of continuity of care has also been something patients have mentioned throughout the co-insight sessions and discussions. Patients are more informed with accurate personal and average data; this amount of transparency better positions patients for driving up service quality. How many appointments have you had? The timeline shows patients whether service usage is increased or decreased over the last 4 years. This may or may not reflect personal health issues but gives patients an understanding of how their needs have changed over time. When do you make most of your visits to your GP? Patients can better plan their visits to avoid busy periods, therefore feeling more in control of how they use the service. These pages have been designed to manage expectation around capacity; allowing patients to be more prepared for waiting if they have to visit their surgery at a busy time of day/week. Your report in detail This is where cost is revealed; displaying what patients have used throughout the year, where they have been, who have they seen, the average cost and whether the NHS has covered the cost. All of the information on these pages has been written in the most

Outcomes

OUTCOME TWO DIABETES APPOINTMENT PLANNER neutral tone possible. Presenting the cost as an average cost and full/part coverage by the service, avoids being explicit, with phrases such as ‘You’ve cost the NHS X amount this year’. Being general with the information at this stage reduces the initial shock of seeing the price of received care. Stating the ‘average cost’ as opposed to simply ‘cost’ makes the amount seem less personal and therefore more palatable to the patient.

The Diabetes Appointment planner allows diabetic patients to track and book their recommended checks and screenings through a smart phone application. Diabetic patients are asked to have a number of regular check-ups to monitor their condition and prevent future complications. This application aims to establish a persuasive rationale for patients to follow this health advice, presenting the cost of treatments to illustrate the value for money.

This portion also acts as the patients own personal record. All of the information combines to create a comprehensive overview of how they have used services over the year, however this more detailed section gives patients a breakdown if they need to track specific conditions or appointments.

A number of smart phone applications currently exist, for measuring glucose levels and insulin such as the ‘Diabetes UK tracker’ and ‘Glucose Buddy’. This suggests there is application literacy amongst diabetic patients, who use their smart phones to manage their health. Although the outcome is not restricted to an application, the format does need to be interactive to support the intervention.

Your prescriptions Similar to the previous spread, this also allows patients to track any medicines they are using. Because most patients will have to contribute to the cost of prescription items, the cost to the patient is shown in direct comparison to the cost to the NHS. This acknowledges in strong contrast the monetary loss to the individual patient, who can see in direct terms, any savings that the NHS makes for them. Your recommended health plan The final spread gives patients a course of suggested action for the next year, based on general age/condition/medication dependant recommendations. Preventative measures are shown against prices and coverage. Communicating the value of reduced risk against the cost (free) has the potential to increase uptake for these measures, improving patient health and saving money long term. Each report allows patients to track their health, creating a telling narrative of how the services have been used. A much more transparent dialogue between service provider and user has been opened although the one-way communication limits how much the patient can respond. If a feedback loop between the user and provider could be developed, patients would be more engaged with their health care and the service would be able to respond better to patient needs.

100

Outcomes

The difficulties of gaining one-to-one feedback from diabetic patients meant that much of the research for this particular outcome had to be conducted using online resources, such as forum sites. These are not a sound enough source to base conclusions upon and would not qualify for recommended practice as the comments are highly unaccountable. However, where possible the information that has been gathered from the forums has been verified through a personal connection with someone who has diabetes. GP Vijay Nayar has also been consulted in order to understand the extent of different diabetic patient care plans. The full e-mail conversations with both individuals can be found in the appendix. After sifting through diabetes forum posts, at Diabetes.co.uk and diabetessupport.co.uk (supported by the charity DiabetesUK), it became clear the application should only focus on appointment reminders. The possibility of charting medicine and supplies consumption was also initially explored, however due to the variations in prescribing and level of condition, different patients are offered different items free of charge. A number of comments on these support forums (Diabetes Support, 2010) described the frustration that some were feeling over not being prescribed what

Outcomes

101

See appendix item: I

they felt was due. Because of the complexity of this issue and the potential to help patients manage appointments better, the application only deals with that side of the service. Having spoken with a diabetic patient about the idea of an appointment planner, it was agreed that despite personally managing his appointments using a diary, something like this would prove useful if office based working was not an option. In addition, a range of online comments pointed to the potential of something to help plan appointments; Andrew Kilman aka Stones2005, posted the following in response to a Guardian - Comment is free section about chronic health conditions - ‘Doctors tell you to self-manage diabetes, but the tools to make it easier aren’t available. I want a single secure place, online, to store all my information about my condition. I want to know what my previous HBa1c (long-term blood sugar tests) and cholesterol levels are. I want to know when my last eye appointment was and reminders for the next one, and I want the GPs to be able to see this too so I don’t have to keep pissing around with new prescriptions for the same drugs that they keep getting wrong’ (The People’s Panel, 2011) Some mention of confusion around appointment planning were also posted into forums, the following are excerpts of such posts: Newtothis Senior member writes on October 12th 2011: Appointments?? ‘Flu jab arranged for the 28th October; I had my retinal eye test a couple of weeks ago; DN going to check my feet in December - are there any other appointment I need to arrange?’ (Diabetes Support, 2011). benniesmum writes on October 13th 2011: NHS going to hell in a handbasket? ‘Is the NHS falling apart or what? Having denied me test strips, I just found out I don’t get invited for the flu jab anymore. Apparently you have to guess when your surgery has the vaccine and call them to find out. No more letters inviting you to come...’ (Diabetes.co.uk, 2011). When consulting with the diabetic patient, it appears that the service currently (in most cases) issues reminder letters for tests.

102

Outcomes

This intervention could replace or supplement those methods, using smart phone technology, making it easier for patients to book with a seamless process as well as communicating the costs within the context of the value being offered. Some online material indicated that some patients were aware of costs, a couple of people had even worked out what they thought the NHS was spending on their care each year. Cate Senior member writes on December 12th 2010: Annual cost of supplies ‘Test strips cost £25 per 50 strips OTC, I get through about 200 a month so £1200 a year. Insulin is about £35 per 10ml I think, 3ml lasts me about 3 days (in a pump) so that’s about 40 vials a year or £1400. When we looked at funding a pump privately, consumables cost about £1200 a year. The pump itself costs around £2000 and needs replacing every 3 years, so write down costs of £700 or so a year. So that would leave me £1500 over budget with nothing left for GP appts, DSN & consultant appointments, flu jab, eye screening & treatment, ramipril to protect the kidneys, statins for cholesterol, plus any random illness that crops up over the year. On the plus side, my husband is very healthy and rarely visits the GP... perhaps he could lend me some of his budget?’ (Diabetes Support, 2009) Later within the same post, the same member writes: ‘I’ve taken out of the NHS far more than I’m ever likely to put in in tax etc, and I know people knock it, but I pretty much only have good things to say about it - when you need it, it’s always there.’ Robster65 moderator writes on December 11th 2010: Annual cost of supplies‘Test strips @£20*52 weeks. Insulin @£20*52 weeks (pure guess). Tablets @£10*52 weeks (another guess). = £2600 + referrals and sundries as you say. Must be averaging around £4-£5k per year. And we’re the conscientious ones !’ (Diabetes Support, 2009) It could be suggested, that those with long term health conditions are generally more conscious of what care might cost due to the amount of additional care they receive.

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OUTCOME TWO SERVICE DESCRIPTION Welcome screen This phone application would be offered as part of the care plan when someone is first diagnosed with diabetes. For the purposes of a walk through demonstration of how the application works, it is assumed that the application is being used for the first time by the patient.

Diabetes Appointment Planner

About the application A description of the application allowing the user to understand the purpose and reasons for its provision. MBA/MDES COLLABORATION 2011

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Your Diabetes Appointment Planner

About Your Diabetes Appointment Planner allows you to keep track of appointments; notifying you of when and where these can be made. The application has been provided as part of your Diabetes care plan which suggests a number of check-upâ&#x20AC;&#x2122;s and tests each year to help manage your condition.

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Main menu After reading about the application, the user would be presented with a main menu, consisting of three options; your details, planner and history. Two of the options are ‘locked’, therefore the user selects ‘Your details’, which takes them to the next screen.

Main menu Once the details have been entered, another option becomes active, allowing the user to select ‘Planner’. Planner This screen suggests any screenings and appointments that the patient should be having in the near future, within a recommended time frame. In this example, the user selects the most immediate appointment, which is to book a flu jab.

Your details This section essentially allows the application to work; as the user inputs their details, the application draws upon NICE guidelines to suggest appointments and check-up’s. MBA/MDES COLLABORATION 2011

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Planner History

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Your Diabetes Appointment Planner

Your details

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Your Diabetes Appointment Planner

Your details

Planner

This application uses recommended guidelines to suggest when you should be making appointments for check-up’s and consultations with health professionals.

According to your history and details, you are eligible to make the following appointments:

Simply enter the date you were diagnosed with Diabetes and whether you are a type 1 or type 2 to begin using your Diabetes Appointment Planner. Date of diagnosis

23/10/11

Type

Your details

Planner

History

Flu jab

Within 2 weeks

HbA1c test

Within 4 weeks

Eye test

Within 7 weeks

Done

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Your appointment Here the user is presented with a ‘quick fact’ section providing an overview of the treatment. If the user wishes to find out more about the treatment itself, they can select the ‘About’ option. This is also the stage at which the patient can see how much the treatment will cost. This has been intentionally ‘played down’ as the research (and feedback) has indicated that patients with long term health conditions have a heightened awareness of the amount of care received. Communicating costs should not make patients feel guilty, rather that they should take advantage of the value that the service is offering. As previously highlighted, preventative measures such as flu jabs reduce the risk of patient ill health and save money for the service. The intention of this application is to provide a persuasive case for patients to follow health advice. The crux of this argument is presented within this quick fact screen, where the cost has been offset by the service, presenting the treatment as free. About your appointment This page explains the treatment in more detail; it may include information such as what should be expected from the treatment, what will be involved and how it impacts on their overall care plan. By communicating realistic and tangible benefits to patients, the information provides the key reasons for patients to follow their care plan.

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Your Diabetes Appointment Planner

Flu jab

O2-UK

About

Flu jab About the flu jab

When

Please make an appointment for your annual flu jab within 2 weeks

History

Your last appointment for a flu jab was 20th November 2010

You pay

Free

Avg. cost

£10.00

Studies have shown that flu vaccines provide effective protection against the flu, although protection may not be complete and may vary between people. Protection from the vaccine gradually decreases and flu strains change over time. Therefore, new vaccines are made each year and people at risk of flu, such as those who are diabetic are offered the vaccination each year.

Book Cost

From here, it is possible to move to the next screen where the user can book an appointment.

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Locations A list of possible options are shown, allowing the patient to choose where they would like to have their treatment. Depending on the treatment/appointment, different options would be available. By selecting the phone number, they are automatically connected to the surgery. Once the appointment has been booked with the receptionist, the user would press ‘Next’ to set a reminder.

Confirming the appointment A final confirmation screen allows the user to review the booking details before either adding the event to their own phone calendar application or simply completing the process. By selecting ‘Done’, the event is added to the application ‘History’. Main menu To access ‘History’ at least one appointment must have been booked. Now that a booking has been made, the user can access this section.

Setting the date and time The date/time of the appointment is entered. Selecting ‘Next’ moves to the next screen. MBA/MDES COLLABORATION 2011

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Locations

Date

Confirmation

Book an appointment at one of the following General Practices Yorkshire Street Medical Centre 01282 420141 Ruskin Health Care 01282 644123 Rosehill Surgery 01282 876099

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Your Diabetes Appointment Planner

Select the date of your appointment:

Oct

Nov

2011

Dec

2012

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Treatment:

Flu Jab (annual)

Date: Time:

Tuesday 24th November 17:35

Where:

Ruskin Health Centre

With:

Dr Andrew Sibson Specialising in Diabetes

Add to iCal

Your details

Planner

History

Done

Outcomes

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OUTCOME ONE AND TWO INTERVENTION POSITIONING

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rt epo R h alt He

Pre-S erv ice

Di a

At what point do the interventions take place within the patient journey?

ent Planner intm ppo sA te be

The Diabetes Appointment Planner meets both of the projects initial criteria; contextualising the costing information within a service application which adds value, enabling patients to better manage their care.

t-Service Person Pos al A nn ua l

History Within ‘History’, it is possible to view both ‘active’ and ‘complete’ appointments; those which are upcoming and those which have passed. It may also be possible to edit the details for these appointments and add notes for personal reminders, ie. test results. This helps patients to manage and track which appointments they have had, giving an overview of all care received.

80%

c et

siting your G ter Vi P, D oun e n nc tis -e t, ice

History Active appointments:

Se rv

Your Diabetes Appointment Planner

Tuesday 24th November 17:35 Flu Jab Ruskin Health Centre

Complete appointments:

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Monday 5th October

Friday 14th October

Outcomes

The two service interventions take place either side of the actual encounter phase; the Diabetes Appointment Planner primarily sits within ‘pre-service’ as it helps patients to book the appointment. Whereas the Personal Annual Health Report is experienced after patients have used services, reflecting past activity.

Outcomes

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Prototyping

TESTING

FEEDBACK

Two prototypes were produced in order to gauge initial reactions and feedback from both patients and medical professionals.

Personal Annual Health Report

A physical prototype of the Personal Annual Health Report was shown to those who were involved with the co-insight sessions. Each person was supplied with a short set of questions to answer in their own time. An electronic version was also sent to Professor Daniel Steenstra who is head of the Disruptive Healthcare Innovation Initiative at Cranfield, along with Simon Potter, PhD student.

Within the feedback from patients (friends, family and co-design participants) similar concerns were raised, these included: Information privacy Some felt concerned about the personal nature of such information being sent via e-mail/post.

GP Partner at King St Surgery, Vijay Nayar, who has been consulted throughout the project, was sent a version to get some feedback from a GP/service provider perspective.

Cost/benefit The cost for producing the booklet/intervention was brought up, with questions over its purpose considering the NHS funding cuts. It was also asked whether it would be possible to predict at this stage, any speculative costs and savings for producing the intervention.

In order to get responses to the Diabetes Appointment Planner, a step-by-step walkthrough of each screen was written and sent to four diabetic patients. Because only one of these patients was a personal contact, guaranteeing feedback was less reliable.

Motive Some participants questioned why they would receive something like this, what the aim/purpose was, suggesting that a wider national awareness message would be needed to prepare people. Comparative data When asked whether they felt the information communicated â&#x20AC;&#x2DC;value for moneyâ&#x20AC;&#x2122;, it proved difficult to answer by all participants. Three patients felt that they would need comparative data (ie. by country?) to put this information into perspective. One of the questions asked for suggestions of improvements or if any information was missing. The following comments were made: Some suggested that there should be links or contact details to additional online information or support. Future plans for the NHS/local services Time comparisons of growing/falling demand of the NHS Availability of out of hours and local care

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What do missed appointments cost the practice each year? Daniel Steenstra and Simon Potter felt that the booklet could also include the percentage of GP surgery patients who also had, for example high blood pressure or distribution of patients with chronic conditions. On the whole, participants found the personalised information very interesting, and appreciated the added value of using the reports to refer back to over time. The following positive comments were made: It could be useful to collect the booklets over time to refer to when asked by insurance companies The reports have been designed to be archived by the patient if they so wish, providing a tangible, accessible record of health. Clearly laid out with good division of information Using the brand guidelines and ensuring a simple and clean layout, participants have found the report easy to read. Good length The amount of information was neither too much nor too little, peaking the readers interest without overwhelming them with information. It informs rather than (blatantly) preaches Through neutral tone of voice, the report succeeds in not patronising or antagonising patients. The subtlety of creating an appropriate voice for the report took huge consideration; it is pleasing to know that among those participants asked, it is felt this objective has been met.

Practical health advice would prove useful as reminders The recommended health plan provides patients with a clear and practical set of advice which benefits both them and the service in the long term. Participants appeared to appreciate having this information which serves as reminders for patient action. Pre-payment information Oddly, the inclusion of pre-payment information was mentioned at least three times, despite this information being printed on prescriptions already. The information on prescriptions is however printed amongst other content, making it difficult to locate and read. It seems that by presenting this against prescription costs as a way for patients to save money has been useful to readers. Daniel Steenstra has shown particular interest and is keen to begin trialing some prototypes with more patients and GP’s for feedback. In e-mail conversations between myself and Daniel, he writes the following: “I must say that I am really impressed with your work - it should be implemented straight away as is... It needs testing with real patients to see how much information they can process and to assess impact on their behaviour.” Vijay Nayar has also offered some positive feedback, stating that the prototype had captured the project aims successfully. Please refer to the appendix for full patient feedback and e-mail correspondence with Daniel Steenstra, Simon Potter and Vijay Nayar.

See appendix item: J

The personal information makes it more interesting The information is relevant to patients, with one of the comments reading, ‘it provides information about me – therefore I’m interested’. The level of personalisation adds value, with each report completely unique to each person.

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Diabetes Appointment Planner The prototype has received feedback from a number of diabetic patients, gathering a range of reactions. In terms of communicating costs and value for money, the following general statements were made: In response to questions about the brief of this project in particular, patient reactions seemed to fall somewhere between a scale of feeling the intervention would be beneficial to cut waste, to feeling ‘attacked’ by the idea of being told the cost of care. Some patients felt the information could dissuade others from using the service, by worrying or scaring them. Of those who felt angry or annoyed that the smart phone application had been designed to inform of cost, some also commented that for them, the emphasis was on the appointment tracking feature (rather than the costing information). All of these patients had been informed of the nature of the project and its aims to communicate costs, which seems to had affected how people have perceived the outcome. Being explicit about the intention of communicating costs has provoked in some cases some very negative comments. For example, one patient had stated, ‘Well, I’m annoyed that the point of this app is designed to let me know what the cost of care is. Thanks for making me feel like a leaden weight on society, all because of a condition (type one diabetes) that was not caused by anything ‘wrong’ I did. And what’s the point even of making type two diabetes sufferers (who DID cause their own condition) feel like money drains - they’ve got it now, so how are we going to treat it? Really annoyed, because I’d like to think that I contribute to society rather than cause it to raise the retirement age to pay for my health.’ Interestingly, when asked whether they thought the smart phone application successfully communicated costs, the same patient commented, ‘I thought it was all about keeping track of care and leaned towards getting appropriate treatment.’

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Therefore, it would be interesting to test the prototypes with impartial patients who were not told about these purposes to gain truer patient reactions. Other issues for patients, included feeling that administratively the application would be difficult to implement. Some had provided anecdotes of how the service was confusing or inefficient for them, placing doubts in their minds about how the intervention could realistically work. Of the patient feedback gathered, there were also some more positive comments; a couple of people felt the intervention would help to cut wastage of medication or missed appointments. When asked whether the information had made them feel angry, annoyed or any other negative emotion, one opinion read, ‘No, it is written clearly below the ‘free’ cost to the patient as information rather than a negative comment.’ With another stating that seeing the costing information would make them feel grateful to not have to pay. The smart phone application is just one means of communicating costs and at this stage, the focus is with balancing out the range of reactions from patients to something more consistent. One way of testing this more accurately would be to mock-up a real application with patients, without mentioning the aspect of cost. As identified within this small group of patient feedback, the value for patients lies with the application functioning as an appointment tracker, rather than as a means to communicate costs, which when explicitly mentioned, provoked and angered patients. The intention was to build a framework, in this case an appointment tracking smart phone application, in order to include costs. By doing this, patients are not confronted by the costing information alone and are provided with something that is designed to add value to their experience as well as inform of costs. Please find the full patient feedback in the appendix.

Prototyping

See appendix item: K

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CONCLUSIONS The aims of this project were to design interventions that would allow the communication of costs to patients. The intention was never to directly provide solutions to medication non-compliance, missed appointments, unnecessary visits to A&E and other examples of waste. It does however, seek to address the need for increased transparency between the service and the user. These outcomes would need to strike the balance in tone, without making patients feel guilty or antagonised. In order to avoid the negative assumptions of this concept, the information must be presented within the context of a more inclusive intervention, ie. a health report that acts as a personal health record, or a smart phone application that allows patients to manage their health appointments. These interventions inform of the costs and value that the service provides, whilst adding value to the patient experience.

Better informed patients may lead to greater engagement with health care. Having access to personal data has proved interesting and relevant to co-insight participants, with information about them, for them. The service becomes more accountable as it publishes data, illustrating the value that is delivered. If patients are provided with a record of how the service meets their needs, there is the potential to drive up service quality. With greater personal understanding of the costs and value of care, patients are given a framework by which to judge whether or not they have received a quality service.

Patient and co-insight participant feedback has highlighted an underlying suspicion amongst service users, who are reluctant to trust the intentions of this project. It could be argued that the contrast between the current lack of service transparency and this proposal to communicate costs, is unsettling for patients. Coupled with increasing uncertainty over public service futures, it may be suggested that patients are at present particularly sensitive of change, especially of this nature. Although the idea is not new, with many people having possibly considered the cost of their care, the implementation of an intervention such as the health report could create a significant shift in mind set. Not just as a patient, but also as a provider, who would be exposing information that has thus far been on a need to know basis. The project outcomes aim to show patients the value of the care received in return for their contributions. Being more transparent, in this way, with service users has a number of significant benefits.

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125

FURTHER DEVELOPMENT There still remains great potential for this project to be further developed. The findings seem to have just scratched the surface of an idea that requires many more iterations and trialing in order to form a strong enough case for communicating costs. The bulk of the project research has been focused on trying to understand how patients see the service in terms of value for money; something that has proved highly complex and even after the project, difficult to capture. In order to fully appreciate the nuances of how we all think about money and value, it would be interesting to involve those with social science and economics backgrounds. At times, the project extended far beyond my knowledge as a designer, offering huge opportunity for other approaches to compliment the process. The encouraging response from Daniel Steenstra, means that the Personal Annual Health Report may be trialed on a larger scale, through his contacts with a director of public health in a PCT and a GP Commissioning Group. This would be a fantastic opportunity to develop this research further, perhaps within the context of a PhD. This report will be distributed to interested parties with the potential of organising patient trials, gaining professional feedback and developing the project.

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Supporting material

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APPENDIX A

Project proposal Statement of intent: Currently patients have very little or no indication of how much health treatments are costing the NHS. This project aims to study the potential of communicating notions of value through educating patients on these costs incurred. Field of study: ‘Customer expectations are beliefs about service delivery that function as standards or reference points against which performance is judged’. (Zeithaml, Bitner, 1996) This project is essentially about managing customer expectations of the NHS, in particular, with relation to how they might assess the value of the service. One way of doing this, is by communicating the price of the services that they are receiving.

Focus - project theme: This project is a theoretical/conceptual attempt to study current perceptions of value, and furthermore the effects of introducing a benchmark of price for patients. It is by no means a definitive answer to a specific problem, but more of an experimental study. Because the NHS is funded primarily through taxation, the payment process is far removed from the point of service encounter. So, unlike what Dan Ariely terms a ‘market relationship’, where the exchange of money for goods takes place, or a ‘social relationship’, (Ariely, 2009) where social norms such as a hand shake or a hug may suffice, the health service seems to fall somewhere in the middle. In a sense, the service is pre-paid and therefore that part of the process is not in our minds when we are receiving treatment, prescriptions and so forth. Market relationship

NHS

Paid through taxation per month

Zeithaml and Bitner explain; ‘For services high in credence properties—expert services that are difficult for customers to evaluate even after they have received the services—many customers do not know criteria by which they should judge the service’. (1996)

Through a greater, more holistic appreciation of how the system is operating on all levels, patients may be able to better engage with the service.

As the NHS is free at the point of delivery and at no stage are patients told how much procedures, medications, care (etc) are worth in monetary or other terms, it can be suggested that users are unable to set an informed level of personal expectation. As a brief example, most people would know how much an average pair of jeans should cost, however, very few would be able to cost a blood test. Such an example highlights the intangible nature of healthcare; where cost arguably, equates to quality when referring to a pair of jeans, the same cannot be said for a blood test.

are given an additional information tool by which to evaluate the received service as well as having a deeper understanding of the relationship between their health and the National Health Service.

Healthcare falls into such a category; where value is an amalgamation of various intangible qualities. Therefore, by providing a more tangible reference point such as price, patients

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This project is proposing a closing of the ‘gap’ that is occurring between the payment process and service encounter, through communicating costs. Payment through taxes per month

> Time gap

Service encounter whenever required

An online article within the Health Service Journal, reported that last year, prior to the election, representatives from the three main political parties agreed on the notion of informing patients on costs. The then Health Secretary - Andy Burnham, said “I think informing people about the costs of services and using them responsibly is something we probably need to take more seriously, so that when people do take out of the NHS, they understand the value of what they are taking out at every level...it tells people this is the value of the NHS treatment you are receiving”. Norman Lamb, Liberal Democrat health spokesman added, “I’ve speculated about the idea of putting the price of drugs on prescriptions so that people can see how much it costs...Awareness about cost I think is something we should consider.” Also, Conservative health spokesman Mark Simmonds; “I think we need to explore making sure people do understand the respective costs of the choice of services that they have.” (Ford, 2010) As a brief working example of this theory, a Yorkshire PCT, communicated individual patient costs last year. Karen Knapton, NHS East Riding of Yorkshire chair, explained, “This is about promoting awareness of costs, and highlighting some of the unnecessary admissions to hospitals.” She added. “A lot of people are surprised when they see the figures. They expect to have the right to have treatment, and successful operations, but don’t think beyond that… they don’t understand how the system works.” (Health Service Journal, 2010)

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I am of the opinion that persuading people to use services more responsibility, stems from a number of interventions, including ease of information, access to services, educating users on the service process and so forth, rather than a single approach of telling them costs. However, helping people to ‘understand the value of what they are taking out at every level’, or rather entitled to, is worth exploring and may include additional information to just costs (ie. man hours etc). Research questions: The project can be divided into three areas; research, design and development. Research How does the NHS currently communicate value? What are the opportunities for patients to judge this value? What is the relationship between price and value? What are the impacts of patient satisfaction and expectation on the NHS? Research into existing alternative methods of pricing and communication. Design How to quantify and track costs? How to visualise costs? How to band and process costs? At what point does this communication occur? How to communicate costs? Development What are the impacts of this information? How can this project be developed?

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Context - The NHS: When the NHS was founded in 1948, it had three main principles: — That it meet the needs of everyone — That it be free at the point of delivery — That it be based on clinical need, not ability to pay (NHS, 2011) The service was established when Labour government nationalised the healthcare system and made the service free at the point of access. Before the NHS, people had to pay for their health service, ‘Prior to the reforms, the poor often went without medical treatment, relying instead on dubious - and sometimes dangerous home remedies or on the charity of doctors who gave their services free to their poorest patients.’ (BBC, 1998) When the service was introduced, there was a huge surge in numbers from those who could not previously have afforded care; ‘It is a demand which scarcely seems to have abated since 1948 when hospital waiting lists stood at 500,000.’ (BBC, 1998) To this day, the NHS remains free at the point of delivery to any ‘ordinarily resident’ of the UK, bar some costs that occur when patients require prescription medications, dental or optical treatments. (Department of Health, 2011a) Since 1948, The Department of Health has published the NHS Constitution; setting out ‘the guiding principles of the NHS and your rights as an NHS patient’. (NHS, 2011) The Constitution outlines seven key principles: — The NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion or belief — Access to NHS services is based on clinical need, not an individual’s ability to pay —

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The NHS aspires to the highest standards of

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excellence and professionalism

— NHS services must reflect the needs and preferences of patients, their families and their carers — The NHS is accountable to the public, communities and patients it serves — The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population — The NHS is committed to providing best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources (NHS, 2011) It also states the following; ‘The NHS is a national service funded through national taxation. The government sets the framework for the NHS and is accountable to parliament for its operation. However, most decisions in the NHS, especially those about the treatment of individuals and the detailed organisation of services, are taken by the local NHS, and by patients with their healthcare professional. The system of responsibility and accountability for taking decisions in the NHS should be transparent and clear to the public, patients and staff...’ (NHS, 2011) A number of points within the constitution, refer to issues surrounding accountability and transparency, as the NHS strives to be as accessible as possible. However, sourcing the kinds of information that I am hoping to communicate, has proved a challenging task as I am met with reports that require the reader to extract the relevant information. A Guardian article entitled ‘Transparency, not targets, will make a better NHS’, discusses the needs for NHS data to be published in a way that patients can make more informed choices; ‘It is not market forces or targets that drive improvement, but transparency. Patients are not shoppers in a health bazaar or ticks in a box. We

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are the owners of the NHS.’ (Editorial, 2009) It is argued that as ‘owners of the NHS’, patients are only able to trust in the service if there is honesty. (Editorial, 2009) In the wake of Dr Foster’s Hospital Guide, Secretary of State for Health, Andrew Lansley, writes ‘A new culture of openness and transparency will transform patient care. Everyone – patients, the public and other clinicians – will be able to see just how well a particular organisation, team or even an individual is performing. This will create a huge incentive for ever higher levels of quality and patient safety.’ (Lansley, 2010) Dr Foster’s Hospital Guide is annual publication, measuring hospital performance in England. Like much of the data that is referred to when transparency is in question, measurements regarding mortality rates, levels of infection, staff wages and other such information are often the focus. However, the ‘NHS White Paper, Equity and excellence: Liberating the NHS’, sets out the Government’s long-term vision for the future of the NHS; including a ‘patient focused’ approach to information, so called ‘The Information Revolution’. The ‘Information Revolution’, attempts to give ‘people more information and control and greater choice about their care. The information revolution is about transforming the way information is accessed, collected, analysed, and used so that people are at the heart of health and adult social care services.’ (Department of Health, 2011e)

that ‘helps people to stay healthy. For the NHS to be sustainable in the 21st century it needs to focus on improving health as well as treating sickness. This is not about the ‘nanny state’’. It also mentions personal health budgets; ‘Learning from experience in social care and other health systems, personal health budgets will be piloted, giving individuals and families greater control over their own care, with clear safeguards. We will pilot direct payments where this makes most sense for particular patients in certain circumstances.’ (Department of Health, 2008) Personal health budgets are currently being trialled in around half the primary care trusts in England, and aimed primarily at long term and chronic condition patients. According to the Department of Health, ‘a personal health budget allows people to have more choice, flexibility and control over the health services and care they receive.’ (Department of Health, 2011f) This could prove an interesting area to look into in terms of how patients are able to better value the service when they are aware of costs. Summary care records are another area of relevance for this project. The lengthy and expensive process of putting peoples health records onto an electronic system for staff to access continues. An article in the Guardian in 2010 wrote, ‘parts of it – including the core patient record project – are years behind schedule, it is costing several billion pounds more to implement than initially forecast, and has become mired in controversy over privacy issues.’ (Mathieson, 2010)

As a means of further increasing NHS transparency, this project suggests providing visible information to patients about the costs of treatments, falling in line with the idea of ‘patient focused’ information.

A page on the Department of Health website, states that ‘To date, 5.7 million SCRs have been created and 30.3 million patients written to. The current recorded opt out rate is 1.16 per cent.’ (Department of Health, 2011g) Patients have the right to ask to see their health records, but they must see their Doctor; there is little indication of records being available online to access any time soon.

A report published in 2008 entitled ‘NHS Next Stage Review’ by Lord Darzi, established the Government’s plans for the NHS reform for the next 10 years. Within this, he talks of creating an NHS

Whilst all of this information should be beneficial for the patient, it needs to also fulfil the needs of all parties involved, for example the bodies that will be communicating the information.

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An article in the Health Service Journal spoke of the concerns that medical professionals had around introducing the cost data, North Essex MP Bernard Jenkin states, “There’s a lot of information in the health service but everybody’s worried about too many people knowing.” He went on to add, “The reaction I see among most medical professionals is that somehow we’re polluting the clinical environment by introducing this idea of cost.” (Santry, 2010) There will undoubtedly be resistance to the idea that costs can be communicated to patients from all sides of the service, including users. The means of communication will need to strike the right balance; informative without undermining that the fact that patients are fully entitled to this ‘free’ care. Within a more detailed version of the NHS Constitution, there sits a section entitled ‘Patients and the public - your responsibilities’. This includes a number of ‘asks’ of the NHS, that users of the service treat it responsibly: ‘You should recognise that you can make a significant contribution to your own, and your family’s, good health and well-being, and take some personal responsibility for it.’ ‘You should keep appointments, or cancel within reasonable time. Receiving treatment within the maximum waiting times may be compromised unless you do.’ ‘You should follow the course of treatment which you have agreed, and talk to your clinician if you find this difficult.’ (The NHS Constitution, 2010) Although these statements are urging users to think about issues surrounding personal responsibility, at no point do they mention the effects of missed appointments or un-used medications. The semantics have been very well chosen; only through implication is it clear that they are referring to time being wasted (and therefore, costs incurred). As has been identified, the NHS encourages the idea of personal

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responsibility, not just in their constitution but throughout the entire service. Online tools (with varying levels of success) are available allowing anyone to check symptoms or find advice, in the form of NHS Direct, Change4Life, weight checkers, self-assessments, widgets to help you stop smoking, and many more. However, this has not always been the case; ‘The shift within the NHS in focus from sickness and cure to wellness and prevention reflects the fact that the management of long term medical conditions and other issues relating to old age are of increasing concern.’ (NHS, Institute for Innovation and Improvement, 2006-2011) As that statement highlights, over the past 60 years there have been significant changes, not just within the service, but also in terms of the population that it serves. With predictions of an ageing population within the UK; ‘by 2034, 23 per cent of the population is projected to be aged 65’ (Office for National Statistics, 2011), the NHS looks set to deal with more patients than ever before. To get an idea of the existing patient turnover, NHS online statistics indicate that the service deals with 1 million patients every 36 hours, which is 463 people a minute or almost eight a second. (NHS, 2009). In 2010, just under nine in ten people had personally used NHS services. 75% had visited an NHS GP whilst 55% had been an inpatient, outpatient or A&E patient at an NHS hospital. (Ipsos Mori, 2011) With such huge numbers of users, the NHS finds itself under enormous pressures to perform. As Professor Daniel Steenstra explains; ‘Healthcare providers across the world have to deal with a rapidly growing demand; more people live longer due to advances in medicine and improved welfare. Patients have better access to knowledge and expect a higher level of service.’ (Steenstra, 2010) In order to establish at what point the communication of information may take place, it has been useful to map out the different levels within the NHS. The NHS website organises this information by Primary and Secondary Care. Primary Care includes GP Practices, Dentists,

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Opticians, Pharmacists, NHS Walk-in Centres and NHS Direct. Primary Care is currently managed by Primary Care Trusts. Secondary Care covers Emergency and urgent care, Ambulance Trusts, NHS Trusts, Mental Health Trusts and Care Trusts. (NHS, 2010a) The Department of Health is the government department, responsible for public health issues, ‘providing, funding and supporting the NHS’. (NHS, 2010a) Strategic Health Authorities (SHA’s), ‘...manage the NHS locally and provide an important link between the Department of Health and the NHS.’ (NHS, 2010b) Department of Health Strategic Health Authorities Each SHA oversees all NHS Trusts in its area Care trusts Social care services

Acute Trusts Hospitals, A&E

Ambulance Trusts Ambulances

Mental Health Trusts Mental Health Services

the way that the service is used as well as changes from the top on the way that the service is delivered. Funding and expenditures: As previously identified, the NHS is publicly funded through taxation (income and National Insurance); with the 2011 budget putting government spending on health at £126 billion (HM Treasury, 2011). An income of around £21,000 per year would mean a tax contribution of £3.33 a day towards healthcare, (Where Does My Money Go? n.d.) or approximately just over 5% of your salary per year. NHS spending 2009 (NHS, 2009)

20%

Staff

60% 20%

Foundation Trusts

(NHS, 2010a)

Primary Care Trusts GP, Dentist, Optician, Chemist, Walk-in Centres, Minor Injury Units, GP led health centres

As the NHS undergoes substantial changes during the current reforms, this particular structure will probably change. Huge funding cutbacks will place the service under ever growing scrutiny and pressure to deliver high quality care at lower costs. This project should represent an opportunity for changes also in

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Drugs and supplies Buildings, equipment, training costs, medical equipment, catering and cleaning

The chart, displaying data from 2009, shows a clear emphasis on staff spending. More consumable items such as drugs and equipment make up the remaining 40% of a budget of over £100 billion. And, according to the World Health Organisation, at this time the country was spending 9.3% of GDP on health. (WHO, 2011)

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However, in terms of the kinds of costs that I hope to identify; specific treatment costs, taking into account staff wages, drugs and overhead costs and so forth - the Department of Health has published some rough figures dating from 2009-2010. The document, entitled ‘2009-2010 Reference Costs Publication’, includes NHS ‘...expenditure in terms of staffing, goods, services and so on. Reference costs originated from a desire to compare unit costs of healthcare, down to the level of treatments and procedures...’ (Department of Health, 2011b) The data has been collected by providers submitting ‘...a single composite cost return for activity they have provided and for which they are responsible (OWN data); data for activity they have contracted out to the Independent Sector (OUT data). PCTs submit a single composite return as above which also contains data for activity commissioned from the Independent Sector (COM data).’ (Department of Health, 2011b) ‘NHS organisations use the data for reporting to executive teams, benchmarking, contract negotiations and local pricing of nontariff areas.’ (Department of Health, 2011b) As well as the NHS, the Department of Health, NHS Information Centre, Office for National Statistics, Audit Commission, Treasury, Parliament and academics and think tanks also use the data, for tasks such as analysing expenditure healthcare programmes, informing input indicators and for the purpose of Parliament ‘to hold the Department and Ministers to account for the costs of NHS services.’ (Department of Health, 2011b) This data is not designed for public use. From the data that was collected between 2009-2010, the following average costs were extracted (Department of Health, 2011b): Day Case Where the patient has a planned admission and discharge on the same day £675 Elective inpatient stay (Excluding excess bed day costs) Where the patient’s admission to hospital is planned and requires

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staying in hospital for longer than a day £2,845

Non-elective inpatient stay (Excluding excess bed day costs) Where the patient’s admission is not planned, including emergency admissions and admissions for maternity, births, and nonemergency patient transfers, and requires staying in hospital for more than one day £1,360 Excess bed day The costs of bed days that fall outside nationally set lengths of stay(?) £255 Outpatient attendance £100 A&E attendance £95 This has provided me with some initial costs, however it may be that I use PLICS (Patient-Level Information and Costing Systems), to inform the price banding more accurately. I should clarify the difference between reference costs and PLICS: Reference costs ‘This suite of documents provides the most detailed picture available about how £51 billion of NHS expenditure was used by over 400 NHS organisations to treat patients in 2009-10.’ (Department of Health, 2011c) PLICS ‘Patient-level costs are calculated by tracing resources actually used by a patient and the associated costs by using actual costs incurred by the organisation in providing a service or event.’ (Department of Health, 2009)

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It appears that these costs are specifically tracking where patients have consumed at some level, the service. At present, I am unable to find any of this data published within the public domain, possibly as there is not complete take up across the NHS; ‘The NHS, with encouragement from DH, is implementing patient-level information and costing systems (PLICS). The implementation of PLICS is not mandatory but DH strongly supports the use of PLICS within the NHS.’ (Department of Health, 2011d) To get an idea of how many organisations are implementing PLICS, a survey was carried out in 2010. The results showed that ‘Over 95 acute organisations have either implemented a PLICS system,or are in the process of implementing a PLICS system. Almost a further 20 acute organisations are planning to implement PLICS in the next few years.’ (Department of Health, 2010a) I would be keen to explore this avenue later, as it seems that PLICS would offer the appropriate level of detail required to begin processing the costs. ‘Patient-level costing is defined by the ability to measure the resources consumed by individual patients. Resources for inpatients should be measurable for each day or part day from the time of entry and admission to the hospital until the time of discharge. For outpatients and non-admitted A&E attendances, the consumption of resources will be on an occasion of service basis.’ (Department of Health, 2009) As far as I am aware at this stage, costs stem from something called Payment by Results. ‘Payment by Results (PbR) is the hospital payment system in England. Under PbR, commissioners pay providers (NHS trusts, NHS foundation trusts (FTs) and the independent sector) a national tariff or price for the number and complexity of patients treated or seen.’ (Department of Health, 2010b) PbR is currently covering acute care only. ‘The currency, or unit of payment, for the admitted patient care tariff is the Healthcare Resource Group (HRG). HRGs are clinically meaningful groups of diagnoses and interventions that consume similar levels of NHS resources. With some 28,000 codes to describe specific diagnoses and interventions, grouping these

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into HRGs allows tariffs to be set at a sensible and workable level. Under the latest version, HRG4, there are over 1,000 tariffs. Each covers a spell of care, from admission to discharge.’ (Department of Health, 2010b) These HRGs allow conditions to be divided into more manageable groups, for example: HRG Chapter

HRG Chapter Description

A Nervous system B Eyes and Periorbita C Mouth Head Neck and Ears D Respiratory system E Cardiac Surgery, Primary Cardiac Conditions F Digestive System G Hepatobiliary and Pancreatic System ... ... (Department of Health, 2010b) These letters are then added to other parts to complete the tariff code. Basically, there is a rather complex series of actions that take place in order to arrive at a final price, something that I will need to explore further in order to obtain some workable data for testing purposes. Wastage: As the NHS looks for ways to cut costs, from a patient perspective, this may mean using the service more responsibly. Due to a number of factors including poor access to out of hours care, there has been in increase in non-emergency visits to A&E; ‘the last decade has seen a 42% increase in those turning up with routine medical complaints. These include breathing problems, fever and rashes, according to a study in the Emergency Medical Journal.’ (Campbell, 2011)

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In 2010, figures were released, showing that ‘unnecessary’ visits to accident and emergency in the North West were costing the NHS £79.25m each year, apparently enough to fund 752 GP’s. (BBC, 2010) choosewell.org.uk is a response to this problem; getting people to choose the appropriate service for their need. Alcohol related admissions have also increased, with no one main cause being attributed, but a mixture, including low price alcohol and licensing. ‘Statistics show there were 1,057,000 admissions in 2009/10...There were more older than young people admitted. Figures also indicate alcohol dependency costs the NHS £2.41m in prescription items.’ (Meikle, 2011) The admissions include alcohol related accidents, as well as cirrhosis, cancers, heart disease and mental health problems. Another area of potential cost savings, is to encourage the use of all prescribed medications. Various technologies have been invented to help patients to remember to take medications, not just for ones own health, but to also save money from wasted drugs and potential hospital admissions as a result of what is termed ‘nonadherence’. According to NICE (National Institute for Health and Clinical Excellence), up to 50% of prescribed medicines are used incorrectly. (NICE, 2009) Within the same paper, entitled ‘Costing statement: Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence’, NICE indicated that ‘Medicines supplied on prescription cost the NHS £8.1 billion in 2007–08. If as many as 50% of patients don’t take their medicines as recommended, this could mean that £4.0 billion of medicines are not used correctly.’ (NICE, 2009) To clarify, this project is not one complete answer to solving issues around increased personal responsibility, or punishing those who do not comply with what is best for their health. An article in the New York Times explains why this area is so complicated; ‘Unhealthy habits are one factor in disease, but so are social status, income, family dynamics, education and genetics. Patient

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noncompliance with medical recommendations undoubtedly contributes to poor health, but it is as much a function of poor communication, medication costs and side effects, cultural barriers and inadequate resources as it is of willful disregard of a doctor’s advice.’ (Jauhar, 2010) As stated, the focus of this project can not be to solve this issue. Rather, it is a possible part of a solution; in attempting to shift attitudes of the service towards a more complete awareness and understanding of health provision. Service expectation, satisfaction and value: Ipsos Mori, a Social Research Institute, were commissioned by the Department of Health to conduct an ongoing study into public perceptions of the NHS. A paper that was published in April 2011, showed general satisfaction levels within the NHS in 2010, at 70%. However, in terms of how respondents felt about issues surrounding value for money, budgets and waste, opinion was less positive. When asked whether they would agree or disagree with the statement ‘The NHS provides good value for money to taxpayers’, 63% agreed. Similarly, just 36% agreed that ‘The NHS is doing everything it can to reduce waste and inefficiency’, and 25% agreed with ‘The NHS is getting better at managing its budgets.’ Over two thirds agreed that ‘There is waste and inefficiency in the NHS’. (Ipsos Mori, 2011) The paper also highlighted some interesting points around how non-users of the service judge it more negatively than those who had experience; ‘Public satisfaction with the NHS remains high (70%) but is drifting downwards. Most of the fall is due to non-users becoming more critical – perhaps in response to media coverage, as they have no direct recent experience. In contrast, users of the service remain very positive (73% satisfaction rating versus 61% of non-users).’ (Ipsos Mori, 2011) These statistics really only provide very general attitudes; to claim that most people using the NHS are satisfied would require more qualitative research and a clear definition of what satisfaction

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means (as it would vary from person to person). However, although only indicative, the differences between users and non-users perception of the service points towards a lack of expectation management. The paper cites media coverage as a possible reason for the more negative opinion of the service. A quick search indeed returns some less than favourable headlines at the Daily Mail; ‘NHS is short of 4,500 midwives, says health service boss’, ‘Alarmingly high death rates at 19 NHS hospital trusts, influential report reveals’, ‘NHS crisis should be tackled by cutting waste rather than staff, say experts’, ‘NHS ‘to cut treatments’ as it faces record £15 million funding shortfall’, and ‘NHS loses 800 patients’ private files every day’. Although the media, no doubt has some effects upon public perceptions and expectations; there are also a number of other factors that culminate to form a more complete picture of how users assess a service. The concept of how a service communicates messages to users; hence setting their levels of expectation, can fall under the title ‘marketing’. ‘Marketing thus has a key role to play in managing the expectations of customers and matching these as far as possible to the range of services provided.’ (Sargeant, 2009, pp.378) Furthermore, ‘Healthcare information has the capacity to influence satisfaction both directly and indirectly, and in an age when consumers are increasingly expected to make their own decisions in respect of treatments and providers, the role of marketing in communicating effectively with customers will become increasingly crucial’. (Sargeant, 2009) Lovelock and Wirtz, suggest that using ‘vivid information’, will produce for service users, a ‘strong, clear impression on the senses, especially for services that are complex and highly intangible’. (2004)

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It is therefore established, that services, in particular health services provide little tangibility by which users can fully understand how to judge an experience. For instance, ‘the consumer has no real way of being able to assess the competence of a surgeon, for example, either before or after and operation has been completed. The have simply to put their faith in the skills of the medical profession and take everything on trust. Of course patients can and do form opinions about the quality of the healthcare product, based on a whole series of surrogates, including their physical surroundings and the bedside manner of their physician. Ironically it is thus possible for a patient to leave a hospital dissatisfied with the service they have received, even if their operation was performed to the very highest of technical standards. Unfortunately the reverse is probably also true and physicians who are among the least competent of their profession can still attain very high levels of customer satisfaction by paying careful attention to other aspects of the service encounter.’ (Sargeant, 2009, pp.381) Valerie Zeithaml and Mary Jo Bitner, divide the role of expectation in services into two categories; a ‘desired’ service and an ‘adequate’ service. (1996, pp.77) Desired service The ‘desired’ service is ‘the level of service the customer hopes to receive—the “wished for” level of performance. Desired service is a blend of what the customer believes “can be” and “should be”.’ (Zeithaml, Bitner, 1996, pp.77) Adequate service ‘...customers hope to achieve their service desires but recognize that this is not always possible. For this reason they hold another, lower level of expectation for the threshold of acceptable service... the level of service the customer will accept.’ (Zeithaml, Bitner, 1996, pp.78) Between these two levels of expectation sits a ‘zone of tolerance’; ‘You might consider the zone of tolerance as a range or window in

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Predicted Service

Past experience

A Word of mouth Friends, family etc Press and media

Implicit service promises Tangibles Price

Desired Service

Explicit service promises Advertising Letters/contracts

which customers do not particularly notice service performance. When it falls outside the range (either very low or very high), the service gets the customer’s attention in either a positive or negative way.’ (Zeithaml, Bitner, 1996, pp.79)

It would be unnecessary to describe in detail the entire diagram, as although it is largely self-explanatory, my work will be concerned mainly with just the ‘Implicit service promises’. Nevertheless, these promises effect both the ‘Desired Service’ and the ‘Predicted Service’, so it is worth touching on the meaning of these factors.

Zone of Tolerance

Adequate Service Situational factors Random over demand Bad weather

They go on to explain that the ‘zone of tolerance’ varies between customers and types of service that is on offer. For example, ‘the more important the factor, the narrower the zone of tolerance is likely to be.’ (Zeithaml, Bitner, 1996, pp.81) To attempt to summarise their extensive written work, I have adapted a diagram, illustrating the main determinants of customer expectations of a service within a healthcare context, on the following page.

Perceived service alternatives Private hospitals, alternative doctors etc

(Based on Zeithaml, Bitner, 1996, pp.80)

Beliefs about what is possible

Adequate Service

Desired Service

Expected Service:

Zone of Tolerance

Personal needs “I need to feel better”

Adapted from Valerie, A. Zeithaml, Leonard, A. Berry, and A. Parasuraman, within Lovelock, C. and Wirtz, J, (2004, pp.40)

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The ‘Predicted Service’ is, ‘the level of service customers believe they are likely to get... Predicted service is typically an estimate or calculation of the service a customer will receive in an individual transaction rather than an overall relationship with a service provider.’ (Zeithaml, Bitner, 1996, pp.87) The ‘Predicted Service’ affects the ‘Adequate Service’ levels because, ‘If customers predict good service, their levels of adequate service are likely to be higher than if they predict poor service.’ (Zeithaml, Bitner, 1996, pp.87) When customers are setting their expectation levels, prior to service encounter, they are also assessing the levels of risk involved. These fall into the following categories; functional, financial, temporal, physical, psychological, social or sensory. (Lovelock and Wirtz, 2004, pp.36) Within the context of healthcare, the kinds of risk would depend on the kind of encounter. For example, if having a routine check-up, one might be concerned about how long it might take (temporal), or if having treatment, whether your Doctor would be supportive (psychological) or perform the treatment successfully (physical).

been multiple studies into where value lies within healthcare. Factors include; physician interaction, availability of services, continuity/confidence, efficiency/outcomes of care, convenience/ access, choice, information, redress and representation. (Various, cited in Sargeant, 2009, pp.382-383) From this, it is possible to see that a wide and varying array of different factors that take place throughout the entire service experience, from pre, encounter, to post, combine to create a sense of value for the patient.

The diagram below, depicts the value chain of healthcare:

Service Delivery

These kind of expectation may inform a users’ ‘personal needs’ and ‘beliefs about what is possible.’ More specific explanations of service expectation within a healthcare context can be found within ‘Marketing Management for Nonprofit Organizations’. When attempting to map consumer value, Adrian Sargeant cites a number of theories; ‘Fundamentally, organizations are successful when they create genuine value for customers. Hospitals are no exception and they may generate value from making it easy for patients to access their services, from the range and quality of services available, from their admissions procedures, from the friendliness and trustworthiness of staff, from their billing procedures etc.’ (Giola, et al, 2000. Cited in Sargeant, 2009, pp.382). ‘Indeed the value created in the healthcare product will be a complex amalgam of patient satisfaction with many different facets of their experience.’ (Hart and Milstein, 2003. Cited in Sargeant, 2009, pp.382)

Pre Service

Point-of-Service

After Service

Target market Branding Marketing mix

Clinical quality Clinical process Internal marketing Patient satisfaction

Billing Follow-up marketing Follow-on clinical care

Organisational Culture

Shared assumptions, shared values, behavioural norms

Organisational Structure

Function, division, matrix

Strategic Resources

Financial, human, information, technology

Sargeant goes on to explain that over the past 30 years there have

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In the case of the NHS, many of these attributes (see value chain diagram) are not applicable. For example, at present - a billing procedure is not in place. Similarly, there is little or no follow-up marketing. Despite that, there may be an opportunity in this area to introduce the information post-service; informing patients of their service usage data rather than billing.

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In terms of determining service quality and presumably value, Zeithaml, Parasuraman and Berry identified five criteria: — Tangibles — Reliability — Responsiveness — Assurance — Empathy (Zeithaml, et al, 1990, pp.21)

Involvement of, and support for family and carers

— Continuity of care and smooth transitions (Picker Institute, 2009) Although very broad and fairly common sense, these provide a starting point for understanding where patients find value in the service; something which is as difficult to define as satisfaction.

These criteria are referred to as ‘SERVQUAL’ which are ‘core criteria that customers employ in evaluating service quality’. (Zeithaml, et al, 1990, pp.26) The outcomes for this project would come under the title of ‘Tangibles’; which include things like appearance of physical facilities, equipment, personnel and communication materials. (Zeithaml, et al, 1990, pp.21) Picker Institute, who gather more qualitative patient feedback, have published a guide; ‘Using patient feedback’ (to improve services). Within this, they identify eight issues that patients find to be the most important: —

Fast access to reliable health advice

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Effective treatment delivered by trusted professionals

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Participation in decisions and respect for preferences

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Attention to physical and environmental needs

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Emotional support, empathy and respect

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Clear, comprehensible information and support for self-care

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The Kings Fund recognises these issues of ambiguity, and has produced a guide to aid the feedback collection, methods and uses process. On ‘satisfaction’; ‘generally recognised as multidimensional in nature, there is no consensus about exactly which domains should be included or which are most important. Patient satisfaction is sometimes treated as an outcome measure (satisfaction with health status following treatment) and sometimes as a process measure (satisfaction with the way in which care was delivered).’ (Coulter, Fitzpatrick and Cornwell, 2009) Similar problems occur around the word ‘value’, where a number of meanings can be assumed. Demetrios Perdikis, comments of ‘The Innovators Prescription’ (written by Harvard Business School’s Clayton M. Christensen) blog, that ‘our medical care system is missing a framework for understanding the value that patients seek in a medical care encounter.’ (2009) I should be clear that Demetrios is referring to the medical care system in America, however, similarities surrounding issues of semantics also occur in the UK. He defines ‘quality’ as ‘the degree to which something is excellent - can be thought of as an effect of competitive forces acting on the players of each side of transactions occurring in any market.’ And ‘value’ as ‘the relative worth - measured in currency, time, et cetera - of those items being exchanged. The value of what is being exchanged is determined by the participants freely making a transaction.’ (2009) These are useful definitions; communicating value becomes much more variable, where each person will judge it differently depending on the level of need. Demetrios explains

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that; ‘the greater the value that each transacting party places on what it receives relative to what it gives the greater the likelihood for quality to emerge from the exchange.’ (2009) Based on this theory, it could be suggested that the exchange would produce a higher sense of quality if a patient places more value on what they receive than what they give (in taxes). However if it were the other way round; a patient values what they contribute in taxes more than the medical treatment, then they may feel dissatisfied with the level of quality. This leads me to question, ‘what happens when a patient doesn’t know the value of what they receive, but only of what they give?’ Zeithaml, Berry and Parasuraman have identified these discrepancies between ‘the actual service and the promised service’ as Gap4 and Gap5. (1990, pp.44) These Gaps are occurring due to poor communication of information; ‘Gap4 essentially reflects an underlying breakdown in coordination between those responsible for delivering the service and those in charge of describing and /or promoting the service to customers. When the latter group of individuals do not fully understand the reality of the actual service delivery, they are likely to make exaggerated promises or fail to communicate to customers aspects of the service intended to serve them well. The result is poor service-quality perceptions.’ (Zeithaml, et al, 1990, pp.45) Therefore, by communicating this extra information, service users are able understand to a further extent, the service delivery and all that is involved. ‘Making customers aware of hidden evidence of a company’s commitment to quality service could improve customers’ service perceptions. Customers who are aware that a company is taking concrete steps to serve their best interests are likely to perceive a delivered service in a more favourable way.’ (Zeithaml, et al, 1990, pp.45)

The relationship between price and value: Valerie Zeithaml suggests that ‘customer definitions of value may be highly personal and idiosyncratic.’ (Lovelock and Wirtz, 2004, pp.158) Four broad expressions of value: — Value is price — Value is whatever I want in a product — Value is the quality I get for the price I pay — Value is what I get for what I give (Lovelock and Wirtz, 2004, pp.158) Lovelock and Wirtz continue to explain that the last point can be referred to as ‘net value’, which is ‘the sum of all the perceived benefits (gross value) minus the sum of all the perceived costs of the service. The greater the positive difference between the two, the greater the net value.’ (2004) So, in theory, if one pays for their received healthcare through taxes but their service usage costs exceed those of their contributions, then the ‘net value’ should be improved. In addition to this idea, the term ‘consumer surplus’, as used by economists, describes the difference between the amount paid and the amount that a consumer is willing to pay to receive the benefits of a service/product. (Lovelock and Wirtz, 2004, pp.158) Returning to this idea that value is a difficult thing to assess, Lovelock and Wirtz use the example of an electrician, whereby a customer may be surprised to see the amount of a 20 minute call out charge. ‘What they fail to think of are all of the fixed costs that the owner of the business needs to recoup; the office, telephone, insurance, vehicles...effective communications and even personal explanations are needed to help customers recognize and appreciate the value they receive.’ (2004, pp.160) As I have already suggested at the start of the project; healthcare costs cannot be equated to quality in the same way that other goods or services can be. Costs fall under the heading of ‘Implicit service

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promises’, which are ‘service-related cues other than explicit promises that lead to inferences about what the service should and would be like.’ (Zeithaml, Bitner, 1996, pp.89) Therefore, although the price itself is explicit, what that price communicates about the service is implicit. When customers, or patients in this case are unaware of what they are getting from a supplier through lack of knowledge, they may feel vulnerable to potential abuse of honesty. (Lovelock and Wirtz, 2004, pp.171) Ie. if a patient were to find out that a blood test cost exceeded what they thought was a reasonable price to pay, they may feel suspicious of the origins of the calculation.

process is removed from the service encounter stage, shifting all sense of value away from monetary and into the intangible service aspects. Therefore, the perceived value is heavily reliant on the perceived quality of service, nonmonetary prices (time, comfort, convenience sacrifices), and other ‘high level abstractions’ such as health and wellbeing. (Ziethaml and Bitner, 1996, pp.501) This is illustrated below; a diagram showing the relationships between price, perceived quality and eventually perceived value.

Although the patient wouldn’t be paying for the service, the information has nonetheless been disclosed to them with the intention of communicating a sense of value. And that value should be derived from the level of service that they are receiving for the amount that they have paid. Hence, ‘pricing schedules have to be designed with customer perceptions of fairness in mind’. (Lovelock and Wirtz, 2004, pp.171) One way of doing this would be to give as much information as possible into how the price was formed; for instance, the number of people involved in delivering the service, the types of consumables, the number of man hours etc. These are speculative ideas about the outcomes of the project. The primary reason that people may not be able to accurately predict a healthcare cost, is a lack of ‘reference costs’. These costs are price points in our memories, and can consist of ‘the last price paid, the price most frequently paid, or the average of all prices customers have paid for similar offerings.’ (Ziethaml and Bitner, 1996, pp.486) Only if one has treatment in a private setting, can they see how much things have cost when they are presented with a bill or statement at the end of treatment. Therefore, it could be assumed that patients lack any reference cost of treatment, as these are never communicated at any stage. In fact, the entire payment/cost

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Other high-level abstractions

Perceived quality

Perceived monetary price

Perceived value

Perceived sacrifice

Perceived non-monetary price

Based on Ziethaml and Bitner, 1996, pp.500

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‘Perceived monetary price’ is ‘the price the customer perceives the service to be, whereas objective price is the actual price...many consumers do not attend to, know, and remember actual prices of services. Instead they reframe prices in ways that are meaningful to them...’ for example cheap or expensive. (Ziethaml and Bitner, 1996, pp.501) The ‘objective price’ informs the ‘perceived monetary price’ in this way. Zeithaml and Bitner explain what the ‘perceived sacrifice’ means; ‘all that the customer perceives has to be given up to obtain a service’. (2004, pp.501) There are a number of different models within this proposal relating to how expectations are formed, influencing levels of satisfaction and in this chapter - looking at perceptions of value. Based on these examples, I would like create a working model of how patients are currently measuring quality within the NHS, setting their expectations and finding value. This will come at a later stage, and will be formed using discussions and co-design sessions with a user group. Communication and lanuguage - healthcare marketing: I have begun to look at the way in which private health insurance companies market their products, compared to the NHS. However only at a very shallow level and will need to explore this further as I move towards the construction of my message. To briefly illustrate the contrasts in language; on the homepage of the Bupa website, consumers are met with statements such as ‘We know a speedy recovery is important’ and ‘Bupa offers prompt access to necessary treatment’. They will cite ‘prompt and extensive care’ as a standard service entitlement, along with ‘access to quality treatment from consultants and specialists’ and ‘access to clean and comfortable recognised hospitals’ amongst others. (Bupa, 2011)

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Different levels of cover are available; the more you pay, the more services are covered. When outlining what each policy covers, the word ‘benefits’ is used, as in, what benefits will you have access to with this level of cover. These are just some very brief examples of the types of language that private healthcare companies use to attract custom. The NHS by comparison, talks about exercise guidelines, childhood obesity, symptom checkers and a direct link on the homepage to complaints procedure information. A quick check to compare each homepage provides some insight of the conflicting messages; Bupa is comforting, offering support and reassurance with promises of high quality care, whilst the NHS encourages personal responsibility of health. To explore this idea, Steven Pinker, Harvard College professor, talks about the way in which language operates; “Language has to do two things; it’s got to convey some content such as a bribe, a command, or a proposition. At the same time it’s got to negotiate a relationship type.” He goes onto explain the different relationship types as; “dominance”, “communality” and “reciprocity”. (Pinker, 2011) In the case of how the NHS and the private companies are currently communicating with their service users, I would suggest that Bupa is using a ‘reciprocity’ relationship where money is exchanged for goods/services. The NHS however, seems to be communicating via a mixture of ‘dominance’, where users are almost having to accept what they are given and also ‘communality’ whereby patients are sharing this public service. Essentially, I am suggesting that the way in which the NHS is communicating with its users via channels such as their website is by not explicitly ‘reciprocal’ - there is no mention of exchange, only reception. Whether or not the service means to communicate more reciprocally, the other party (the patient) may not be interpreting the message that way. The result leads to a “divergent understanding”; “the key to this paradox is a concept that

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economists and logicians call ‘mutual knowledge’, which they distinguish from ‘individual knowledge’”. (Pinker, 2011) ‘Mutual knowledge’ is where both parties know what they know, they also know what the other party knows, they also know what the other party knows they know and so on... To conclude what may seem like a slightly irrelevant point; the message that I am communicating on behalf of the service, will need to be explicitly reciprocal in intent, ie. in basic terms; this is what you contribute, and this is what you receive. Disruptive innovation within healthcare: Professor Daniel Steenstra has written a paper, entitled ‘Innovating the NHS - Now or Never’. Within this, he argues that the service needs to innovate, rather than simply increase productivity whilst cutting costs. Describing the aspects needed to deliver innovation; ‘developing new, more effective services will drive the use of new technologies and products but also change the attitudes of employees, organisational structure and leadership.’ (2010) Daniel explains that in the past, any initiative to encourage innovation was hampered because of the isolation of one of these elements. Steenstra continues to blame the top-down hierarchy and target setting approaches adopted by the organisation. ‘Measures such as awarding Foundation Trust status to financially sound organisation; outsourcing services to the private sector and PCT commissioning has actually led to competition...good practice or mistakes are not shared.’ (2010)

the passivity of the patient role as the reason for this. ‘Something changes in people when they become patients. As consumers they are informed and empowered and can easily assert their choice by shopping elsewhere, buying other products or changing service providers. Somehow when they get a diagnosis of a disease there is a change in their behaviour. They seem to readily accept inefficient services and ineffective products; they are not up to date with the latest developments in their condition and with new products that could support them better... Patients are reluctant in engaging with market research; they feel that they are owed the best medication, products and services but do not want to support their development. This makes it difficult for the companies to develop better products and services.’ (2010) With an increase in demand, reduction in funding and a complete political shift, Daniel states that the NHS is left in ‘...desperate need of innovative service and products on a scale not seen before and established industry and academia that are unlikely to satisfy that demand.’ (2010) However, a glimmer of hope comes in the form of the opportunities created through the removal of SHA’s. ‘There is a window of opportunity to lead the way in a new model of innovation and collaboration. This has to: be internally driven and focus on news services, integrated with new products and organisational change.’ (2010)

Essentially, he establishes a strong argument that the NHS is not well equipped to innovate; ‘The NHS doesn’t have a history or capability to innovate; it never had to be innovative - just to provide patient care. So far it has only considered innovation to be product related.’ (2010)

Jason Hwang, based on ideas and research by Professor Clayton Christensen, is critical of the knee-jerk reaction of cutting costs; ‘The problem is the solution shop activities of hospitals and of diagnostic work is inherently expensive and complex...and to make sure that they continue delivering value to the healthcare system, cutting reimbursement rates to those people and those technologies is not the right solution...what we need to do is find ways to get that technology into the right business models that can use them in a cost-effective manner in the marketplace.’ (2009)

Discussing in particular, the ways in which patients cannot drive innovation, in the same way that consumers can; Daniel attributes

The ‘solution shop’ activities that Hwang is referring to, describe the business model of general hospitals who are working to find out

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a problem and suggest a solution, as opposed to just delivering a standard procedure. (2009) The three conditions that enable disruptive innovation are: — Technologic enabler ‘...the technology that makes a product or service simpler and more affordable.’ — Business model innovation ‘...in which you embed that technology into a business model that can take that technology in a cost-effective way into the marketplace.’ — Commercial system ‘...to coalesce around a disruptive business model, to support it as it goes to market.’

I will need to find a way of marrying up the objective costs of treatments and subjective notions of value. For this, it may be useful to look at applying methods employed by behavioural economists.

There seems to be a real potential, looking at the theories around value and expectation, for this project to alter how the service is used, or at least perceived. In what way exactly, I have yet to discover, but the research does indicate some strong arguments for the benefits of communicating costs. Methodology - research plan: The research methods for this project cover a mixture of primary and secondary resources.

(Hwang, 2009)

Over the course of the project I will need to get in contact with a number of ‘experts in the fields’ of healthcare, policy, innovation and possibly behavioural economics.

Although this project is neither a technology based innovation nor a product (although technology will enable it to happen); it is concerned with disrupting the current perceptions of a service, and in turn affecting behaviours.

Vijay Nayar GP Partner at King St Surgery, Kempston and Putnoe Medical Centre, Associate Postgraduate Dean, East of England Deanery and Visiting Fellow at Cranfield University

Context review: The context for this project has covered, and will continue to cover a wide breadth of subjects, from the organisation itself to more abstract notions of behaviours and value. Some of the chapters within this section have been more detailed than others; my knowledge in these areas is therefore more informed. Thus, as the project moves forward I would like to further explore some of the ideas that I have begun to touch upon, such as the ways in which language will have an effect on how service users perceive the value of what they are receiving.

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I met with Vijay Nayar, on 7th July, to discuss the project in general terms in order to gain some insight from a health professional. The following lists the feedback given: — Vijay saw the project as having two possible directions; one looking at the rate and reasons behind ‘Did Not Attend(s)’, where it would be interesting to track the rate of ‘DNA’s’ over time to see if interventions had had any effect. He also suggested that I may try to contact those patients who do not attend appointments to find out why, however there lies the difficult issue of confidentiality. The idea was to focus on the differences between user perceptions of value. For example, he provided anecdotal evidence that suggests that older people value the service more highly. Vijay also spoke of the cultural differences in service users, whereby if the level of

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healthcare in another country was not free or by comparison more difficult to access, the patient would treat the NHS differently as a result. — The ethical issues surrounding patient access were also discussed. This is something that I may be able to carry out using a group of people that I know personally who have had some experience of the service. — When speaking about the kinds of targets that he has to meet as part of the service provision, Vijay told me about ‘Script Switch’. This is something that prompts Doctors to choose alternative, cheaper prescription medication. He also described annual reports that each practice receives, that display data of their performance against other practices. This would include things such as, number of referrals, number of admissions and so on, in an attempt to reduce numbers and therefore costs through a kind of peer pressure. — In terms of patient value, Vijay listed off a number of recognised points; continuity of care (always seeing the same Doctor), ease of access, having a say in the decision making and a number of others that have been established by official bodies. He told me that Putnoe Medical Centre is about to introduce a ‘Patient Reference Group’ which would consist of roughly 10% of their total number of patients. This would be a representative group of people whom they would contact for feedback on new or removed services. This seems to be something that each practice has in place, and upon a brief internet search, some groups are larger, and therefore more representative than others. There is also something called a ‘Patient Participation Group’ which is longer established and has a much smaller group of people involved. — We spoke about the different research methods that I could use; Vijay suggested a questionnaire to see how accurately people could guess costs. On reflection, this may be better carried out as part of a co-design exercise. —

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people were told about costs, he felt that people would be apathetic. There is clearly some way to go in this project before I can say that with any level of certainty that it would have some effect.

The meeting was useful to get some detailed initial feedback, although Vijay was clear that I needed to be very focused on what I was trying to do; that I would need to choose an area (context) to focus the project. The following group of people are those which I have yet to speak directly with or those whom I am hoping to present my finding to at the end of the project. Daniel Steenstra Royal Academy of Engineering Visiting Professor in Innovation Daniel has written a paper which I have referenced in this proposal on Innovation within healthcare, a category that I feel this project would fall into. I would also, like to speak with Daniel as he has been instrumental in contacting others for interest in the project. He has contacted and received responses from George Leahy and Paul Hodgkin. Paul Hodgkin Patient Opinion Paul runs a website that allows patients to leave feedback on their experiences, which in turn are read and acted upon by the responsible party. In terms of improving patient perceptions of value, Paul would be a good person to present to for input. George Leahy Deputy Director, Innovation Policy Team at DOH Daniel has received a response also from George Leahy, again from

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the perspective of innovation within healthcare. I may not contact George for an interview, but I would like to present him with my findings. Suraj Bassi Assistant Manager, Government & Infrastructure Healthcare at BDO I met Suraj at a seminar and we spoke about the idea of using behavioural economics techniques within healthcare. He told me about a project that he was involved with, looking at reducing missed appointments using theories by Robert Cialdini (see case study - HMRC letter). Karen Knapton Chairman - East Riding NHS Primary Care Trust Karen was involved with a similar project at East Riding of Yorkshire PCT and I am very keen to speak with her about the results of this. Jerry Fishenden Specialist Adviser at House of Commons: Public Administration Select Committee, Director and Co-Founder at Centre for Technology Policy Research, Visiting Senior Fellow at London School of Economics and Doctoral Researcher at Institute of Creative Technologies amongst others...

Online feedback: To get some initial feedback, I posted a description of the project on DotGovLabs Innovation Hub -‘The Innovation Hub brings together the know-how of professionals, policy makers and real people, providing opportunities for skilled and experienced people to participate in government. In creates collaboration across government departments, non-profit organisations, businesses and individuals; finding new and innovative ways to solve problems together using digital technology.’ (DotGovLabs, n.d.) The responses are as follows. Posted by Tim Knight 28/06/11: — I think its a good idea, tell people how much they cost the NHS and make them think about whether or not they actually need the help, and/or make sure they respect the help they get. I watched a woman on television the other night saying she hadn’t stuck to her diet after getting the gastric band, and ok she went private so it didn’t cost the NHS but you know there are plenty of people out there that don’t respect the kind support they have received, maybe if they knew how much it costs they might? Posted by Carl Plant 28/06/11: — Amy I think you need to research what patients value during an episode of ill health, treatment and engagement with healthcare services. It seems you’re focusing too much on trying to change people’s perception towards healthcare costs in a bid to alter levels of responsibility, without discovering their values and beliefs first. I would advise you to be very mindful when researching if ‘people are taking healthcare for granted’. Patients attitudes to health are shaped through their (and friends/relatives) experience of the NHS as well as socially constructed reputations. This has to include the paternalistic and potentially disempowering framework found in some parts of the healthcare system. You will need to look at the research into patient choice to discover what patients value when making health choices and locus of

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control.

Posted by Sandie Bakowski 29/06/11:

An area you may find success in is not on how much does treatment cost but on the perception of ‘not burdening healthcare staff/ services’. The bit where patients don’t want to waste GPs/HCPs time and by disengaging with services actually create more need further down the line. Finally, for a patient to be informed to make decisions based on quality of service vs cost, you will discover that quality is certainly a challenge to define and make meaningful for lay people.

— Agree it needs targeting as needs thought about the reaction and if people start resenting others use of services but I think it’s worth exploring.

Posted by Erica Lewis 29/06/11: — This is a good thought - so many people who have benefited from the NHS over the years are horrified to see the price their US (etc.) counterparts pay for their healthcare. However I think there are areas that visibility would work well as well as those where it may have the opposite effect. In my local GP surgery there is a wall display advising patients of the cost in the US of a GP’s appointment, hoping to avoid people not turning up to their appointments and wasting doctors’ time. This strikes me as a sensible use of this information. On the other side of the coin, things such as vaccines may be seen as a waste of money and take-up may drop. As may antenatal classes, smear tests etc. Compromising one’s own health may be seen as a public service, saving taxpayers’ money in times of austerity. I appreciate that low take-up of these early services increases costs further down the line, but people aren’t going to see that. The likelihood of them personally being affected are relatively small, and people tend to discount the future anyway (preferring £50 now to £100 this time next year, for example). Actual cost to the NHS increases in this case.

I’ve addressed each of the comments; some of the issues surrounding targeting the outcomes and identifying where patients find value will be developed as the project moves forward. The site has provided a good platform for feedback in a noncommittal, open environment. Literature and secondary research: I have and will continue to use literature and established models around value, satisfaction, expectation and price. Literature on service marketing by Christopher Lovelock, Jochen Wirtz, Mary Bitner, Valerie Zeithaml, Leonard Berry and A. Parasuraman all reference these topics. I will also be looking for material around behavioural economics, by authors such as Dan Ariely and Robert Cialdini. Articles within quality newspapers such as the Guardian and magazines including Wired will be used to contextualise the project. For the data around price and quantitative research figures, I will be using sources such as the Department of Health, World Health Organisation, Ipos Mori and NICE publications.

I still think the idea is good - it just needs to be carefully targeted.

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Co-design and qualitative research methods: I will be primarily employing co-design methods throughout the project; at initial stages when gathering qualitative insight, then at a later stage during testing. However, before I can begin the codesign, I must first establish for myself, exactly where and how patients are assessing value within the service. In order to do this I will need to speak with a group of service users; these can be friends and family (who have had experience). To create a group, I need to issue a short questionnaire to determine service usage level; frequency, breadth of service use, ie. GP, Hospital, Dentist etc. The results should then indicate who would be suitable for the co-design exercises; by choosing a range of people, with a mixture of service interactions levels. To collect data around value and user experience, I would like to design sets of issue cards, that will allow me to understand how people currently perceive the service. Stage one methods: — Using cards as prompts, an array of different service attributes around value will be printed onto cards for the participant to order in a hierarchy of ‘most valued’ to ‘least valued’. From this, I hope to see patterns emerging around groups of people valuing different or similar things. — Printing analogies in the form of images or words to establish metaphors for the service, may give insight into how different people view the NHS. — Printing different service providers on each card, ie. phone, transport, insurance etc alongside the health service to see how it fares in comparison to others in terms of importance (valued) Or perhaps if one of these services was to be removed/reduced, which one would be most popular? — Using an alternative ‘product’ such as cars, or clothing, I would like to see how successfully participants are able to match product to price. This can then be compared to healthcare, whereby products are replaced by treatments/medication etc.

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— Another pricing activity; a number of treatments printed onto cards whereby people can estimate how many treatments can be carried out for a set amount of money. — Using the notion of ‘consumer surplus’ as described on page 31 of this proposal, I would like to find out how much people would be willing to pay for a variety of routine medical tests/ medications. From these initial research methods, I hope to then be in a position to focus my project on a chosen group of people. Stage two methods: — In order to create profiles for each of the participants, I would like to map their service encounters. This may be done using templates of time lines and filling out with them, at what points did they have an interaction, at any level, with the service. — Emotional mapping of their service journey, to spot possible information interventions (ie. maybe it occurs only when they felt good about the service, perhaps on discharge). — I would like to ascertain the kinds of service interactions that the group are having with other providers. For example, methods of correspondence/channels of communication. Additional methods will emerge with each stage as the project moves forward, however, I can say with certainty that the testing stage will involve the following: —

Initial mock-ups

—

Experience prototypes

—

Story boarding to communicate the ideas

At this final stage of development, I should have in place a blueprint for how the outcome will work in context along with detailed user profiles.

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Case studies: Where Does My Money Go?

Statements vs. bills

An online service, which displays government data in a user friendly format. There are a number of different ways to view the data, with perhaps the most interesting being where a yearly salary can be entered, to return how the taxes are spent in very specific amounts. ‘Users of the service would be able to see where their own money is spent or where it comes from, as well as where money across government is spent and where it comes from. Existing government transparency would be built upon to help citizens discover their own part in government economic activity — thereby encouraging them to take a more active interest in, and a more thoroughly informed engagement with, the official institutions around them.’ (Where Does My Money Go? n.d.) OPower Software business OPower, has created a disruptive approach to energy supply, through data comparative energy bills. The bills show how you, as an energy consumer are performing against your neighbours. Using a theory around ‘social proof’, a recognised ‘weapon of influence’ by Robert Cialdini (author of Influence - The Psychology of Persuasion), the bills exploit social pressures, rather than financial or other incentives, in order to change behaviours. (Watts, 2011) HMRC letter The Cabinet Office’s Behavioural Insight Team, have been working on a number of projects with advice from Professor Thaler. According to an article in the Independent, a single line of text was changed on tax repayment letters to read ‘The normal repayment rate is about 50 per cent. 94 per cent of people pay their tax on time. Even if one person doesn’t it has a significant impact.’ (Hickman, 2011) It also stated that the repayment rate increased by 85%, collecting £200m in that experiment alone.

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A clear distinction that this project should make in terms of language (both semantically and visually), is that the information is not being communicated to prompt payment. It is not a bill, more like a statement of usage. I would like to look at the ways in which the two differ and possibly employ some of the same conventions. University fee changes Over the course of my education, I have seen tuition fees rise from between £0-£1000 to £3000 and now to a possible £9000 a year. I would like to take a look at how perceptions of this ‘service’ value has changed as fees have come in to play. Some online comments made on TellYouGov, are in the majority negative responses; “I don’t think the universities (such as Durham) now wanting to charge £9000 are prepared for students demanding a consumer oriented “value for money” approach to their university experience.” (TellYouGov, 2011) Although this is not representative of everyone, I would imagine that similar opinions are felt across the country, as young people are having to make decisions based on financial situation as access becomes more limited. Parallels between issues surrounding education may be made with the health system in terms of how expense has a knock on effect on levels of expectation. Council tax I would also like to look at how people are paying their council tax; what information is available to them regarding where the money will be spent and the tax banding system. This is the means by which people are gaining access to healthcare,

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through contribution. Therefore, there may be links that I can make between contributions and usage.

Bibiliography: Ariely, D., 2009. Predictably irrational : the hidden forces that shape our decisions. London: Harper

Outcomes: The proposed project outcomes can be described as service interventions, to change the way that people are currently understanding the value of the service.

BBC, 1998. The NHS: ‘One of the greatest achievements in history’ [Online] Available at: http://news.bbc.co.uk/1/hi/events/nhs_at_50/ special_report/123511.stm [Accessed: 7 July 2011]

These may take the form of: — Annual statements Service users would receive these statements, illustrating service usage over a period of time. This could also include extra information on contributions and post-service health advice. — SMS messages or ‘receipts’ Sent/given out each time the service is used. — General tariffs Costs are published in public domains, clear graphics indicate general costs in a ‘menu’ like format. This could be combined with the receipt. — Quotes Pre-service ‘quotes’ are given to understand how costs are derived. Think online booking services (perhaps coupled with online ‘choose and book service’). It may not be any of the above, these are purely speculative suggestions to communicate the idea in context. As stated, I will need to continue to explore how value is currently being judged and design the outcome with this in mind. This will be an ongoing study into notions of value within the NHS with the intention of extending existing benchmarks of value to include costs.

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BBC, 2010. North West England patients’ A&E misuse costing £79m [online] 1 November. Available at: http://www.bbc.co.uk/news/ukengland-11664340 [Accessed: 8 July 2011] Bupa, 2011. Bupa homepage. [online] Available at: http://www.bupa. co.uk/ [Accessed: 12 July 2011] Campbell, D., 2011. Child A&E admissions prompt calls for better out-of-hours care. Guardian. [online] 24 May. Available at: http://www.guardian.co.uk/society/2011/may/24/children-accidentemergency-nhs-report [Accessed: 8 July 2011] Coulter, A., Fitzpatrick, R., and Cornwell, J., 2009. The Point of Care Measures of patients’ experience in hospital: purpose, methods and uses. The Kings Fund [online] July. Available at: http://www. kingsfund.org.uk/publications/measures.html Department of Health, 2008. NHS Next Stage Review Final Report – Summary [Online] Available at: http://www.dh.gov.uk/ prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/ digitalasset/dh_085826.pdf [Accessed: 8 July 2011] Department of Health, 2009. Definition: patient-level information and costing systems. [Online] Available at: http://www.dh.gov.uk/ en/Managingyourorganisation/NHScostingmanual/DH_080055 [Accessed: 22 June 2011] Department of Health, 2010a. Patient Level Costing & Information Systems (PLICS) Survey 2010. Summary of Results. [Online] Available at: http://www.dh.gov.uk/prod_consum_dh/groups/ dh_digitalassets/documents/digitalasset/dh_122397.pdf [Accessed:

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22 June 2011] Department of Health, 2010b A simple guide to Payment by Results [online] Available at: http://www.dh.gov.uk/prod_consum_dh/ groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/ dh_120254.pdf [Accessed: 8 July 2011] Department of Health, 2011a. Eligibility for free hospital treatment under the NHS. [Online] Available at: http://www.dh.gov.uk/en/ Healthcare/Entitlementsandcharges/OverseasVisitors/Browsable/ DH_074374 [Accessed: 17 June 2011] Department of Health, 2011b. UseReference Costs 2009-10 Publication. [Online] Available at: http://www.dh.gov.uk/prod_ consum_dh/groups/dh_digitalassets/documents/digitalasset/ dh_123501.pdf [Accessed: 22 June 2011] Department of Health, 2011c. NHS reference costs 2009-2010. [Online] Available at: http://www.dh.gov. uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_123459 [Accessed: 22 June 2011] Department of Health, 2011d. NHS costing and cost collection. [Online] Available at: http://www.dh.gov.uk/en/ Managingyourorganisation/NHScostingmanual/index.htm [Accessed: 22 June 2011] Department of Health, 2011e. An Information Revolution: a consultation on proposals. [Online] Available at: http://www.dh.gov. uk/en/Consultations/Liveconsultations/DH_120080 [Accessed: 6 July 2011] Department of Health, 2011f. Personal health budgets pilot programme [Online] Available at: http://www.dh.gov.uk/en/ Healthcare/Personalhealthbudgets/DH_109426 [Accessed: 8 July 2011] Department of Health, 2011g Summary Care Record mailings to

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patients resume [online] Available at: http://www.dh.gov.uk/en/ MediaCentre/Pressreleases/DH_125690 [Accessed: 8 July 2011]

Dixon, A., and Dickson, N., 2008. Engaging Patients in their Health How the NHS needs to change. The Kings Fund. DotGovLabs, n.d. Philosophy of the Innovation Hub. [online] Available at: https://dotgovlabs.direct.gov.uk/Page/Philosophy [Accessed: 10 July 2011] Editorial, 2009. Transparency, not targets, will make a better NHS. Guardian, [Online] 29 November. Available at: http://www.dh.gov. uk/en/Healthcare/Entitlementsandcharges/OverseasVisitors/ Browsable/DH_074374 [Accessed: 22 June 2011] Ford, S., 2010. Parties agree on need to tell patients about NHS service costs. Health Service Journal, [Online] 30 April. Available at: http://www.hsj.co.uk/news/policy/parties-agree-on-need-totell-patients-about-nhs-service-costs/5014186.article [Accessed: 6 July 2011] Health Service Journal, 2010. PCT tells patients the cost of their care and services. Health Service Journal, [Online] 20 May. Available at: http://www.hsj.co.uk/news/primary-care/pcttells-patients-the-cost-of-their-care-and-services/5014733. article?MsgId=115763 [Accessed: 6 July 2011] Hickman, M., 2011. Nudge, nudge, wink wink... How the Government wants to change the way we think. The Independent. [online] Available at: http://www.independent.co.uk/news/uk/politics/ nudge-nudge-wink-wink-how-the-government-wants-to-changethe-way-we-think-2174655.html [Accessed: 11 July 2011] HM Treasury, 2011. 2011 Budget - Easy-to-browse Budget document. [Online] Available at: http://www.hm-treasury.gov. uk/2011budget_easyread.htm [Accessed: 17 June 2011] Hwang, J., 2009. Keynote address - The Innovatorâ&#x20AC;&#x2122;s prescription. An examination of the future of Healthcare through the Lenses of

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Disruptive Innovation. Arch Pathol Lab Med-Volume 133. pp. 513520 Ipsos Mori, 2011. Public Perceptions of the NHS and Social Care; An Ongoing Tracking Study Conducted for the Department of Health, December 2010 Wave. [Online] Available at: http://www.wmqi. westmidlands.nhs.uk/downloads/file/Public%20Perceptions%20 DEC%2010.pdf [Accessed: 19 June 2011] Jauhar, S., 2010. No Matter What, We Pay for Othersâ&#x20AC;&#x2122; Bad Habits. The New York Times [online] 29 March. Available at: http://www. nytimes.com/2010/03/30/health/30risk.html [Accessed: 8 July 2011] Lansley, A., 2010. Andrew Lansley: An open, transparent NHS is a safer NHS. Guardian, [Online] 27 November. Available at: http:// www.guardian.co.uk/society/2010/nov/27/andrew-lansley-doctorfoster-comment [Accessed: 22 June 2011] Lovelock, C., and Wirtz, J., 2004. Services marketing: people, technology, strategy. Upper Saddle River, N.J. : Pearson/Prentice Hall Mathieson, SA., 2010. Online health records can save lives. Guardian, [Online] 13 January. Available at: http://www.guardian. co.uk/society/2010/jan/13/online-health-records-saving-lives [Accessed: 8 July 2011] Meikle, J., 2011. Alcohol-related hospital admissions at record high. Guardian. [online] 26 May. Available at: http://www.guardian. co.uk/society/2011/may/26/alcohol-hospital-admissions-recordhigh?INTCMP=SRCH [Accessed: 8 July 2011] NHS, 2009. About the NHS - Overview. [Online] Available at: http:// www.nhs.uk/NHSEngland/thenhs/about/Pages/overview.aspx [Accessed: 17 June 2011] NHS, 2010a. About the NHS - Structure. [Online] Available at: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/

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nhsstructure.aspx [Accessed: 22 June 2011]

NHS, 2010b. About the NHS - Trusts. [Online] Available at: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/ authoritiesandtrusts.aspx [Accessed: 22 June 2011] NHS, 2011. About the NHS - Principles. [Online] Available at: http:// www.nhs.uk/NHSEngland/thenhs/about/Pages/nhscoreprinciples. aspx [Accessed: 21 June 2011] The NHS Constitution, 2010. The NHS Constitution - Interactive version [Online] Available at: http://www.nhs.uk/choiceintheNHS/ Rightsandpledges/NHSConstitution/Documents/nhs-constitutioninteractive-version-march-2010.pdf [Accessed: 7 July 2011] NHS, Institute for Innovation and Improvement, 2006-2011 Prevention is better than cure [Online] Available at: http://www. institute.nhs.uk/building_capability/technology_and_product_ innovation/prevention_is_better_than_cure.html [Accessed: 7 July 2011] NICE, 2009. Costing statement: Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence. [online] Available at: http://www.nice.org.uk/nicemedia/ pdf/CG76CostStatement.pdf [Accessed: 8 July 2011] Office for National Statistics, 2011. Population, ageing [Online] Available at: http://www.statistics.gov.uk/cci/nugget.asp?id=949 [Accessed: 25 June 2011] Perdikis, D., 2009. The Confusion of Shifting Value. The Innovatorâ&#x20AC;&#x2122;s Prescription, [online] 25 April. Available at: http:// innovatorsprescription.com/profiles/blogs/the-confusion-ofshifting [Accessed: 10 July 2011] Picker Institute, 2009. Using Patient Feedback. [online] Available at: http://www.pickereurope.org/Filestore/Quality/Guides/QIFull.pdf [Accessed: 10 July 2011]

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Questionnaires: A

Pinker, 2011. Language as a Window into Human Nature. RSA Animate. [video online] Available at: http://www.youtube.com/ watch?v=3-son3EJTrU [Accessed: 12 July 2011] Santry, C., 2010. Patients should be told the cost of their treatment, says Tory MP. Health Service Journal, [Online] 5 October. Available at: http://www.hsj.co.uk/news/finance/patients-should-betold-the-cost-of-their-treatment-says-tory-mp/5020130.article [Accessed: 6 July 2011] Sargeant, A., 2009. Marketing Management for Nonprofit Organizations. Oxford: Oxford University Press Steenstra, D., 2010. Innovating the NHS - Now or Never. Innovations Factory Ltd. TellYouGov, 2011. How do you feel about University Fees? [online] Available at: http://tellyougov.com/topics/19122?in-the-last=1month [Accessed: 12 July 2011] Watts, M., 2011. The Neighbourhood Energy Revolution. Wired UK edition, pp. 96-101. Where Does My Money Go?, n.d. Where Does My Money Go? Showing you where your taxes get spent. [Online] Available at: http://wheredoesmymoneygo.org/ [Accessed: 17 June 2011] WHO, 2011. United Kingdom (Total expenditure on health as % of GDP (2009)). [Online] Available at: http://www.who.int/countries/ gbr/en/ [Accessed: 21 June 2011] Zeithaml, V., Parasuraman, A., and Berry, L., 1990. Delivering Quality Service. Balancing Customer Perceptions and Expectations. New York: The Free Press Zeithaml, V. and Bitner, M., 1996. Services Marketing. Singapore: McGraw-Hill Book Co.

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Co-Design:

Involving service users throughout the design process to reach a more holistic and appropriate outcome

Thank you for agreeing to take part in these co-design sessions to help with my project. These will take course over 2 sessions: 1. Information gathering The first session will include a number of exercises, with the aim to understand how NHS users currently find value within the service. These will be short activities/games. The second part of the first session will involve the creation of a detailed customer service journey map, which shows at what point you had an interaction with the service. This may be a recent interaction you had or perhaps multiple interactions within the past year. This should take place over the next couple of weeks and last around 1-2 hours. 2. Prototyping and Feedback The second session will provide the opportunity for me to get some initial reactions and feedback from you. I will bring along a number of possible design solutions as rough prototypes. This will take place at some point in September.

This questionnaire and the co-design sessions will require some personal information about your health. I will also need to document the sessions by photographing the process and results. This information will be used in order to refer to genuine user experiences from a range of service users. Because of the sensitivity of some of the data, I will change all names and guarantee that the photographs do not capture any faces to ensure anonymity. Once I have established some ‘norm’s for different types of service users, the data will then go on to help me form generic user profiles. These will be fictitious characters that represent a type of service user, which enable me to design for a specific group of people. For example, ‘Bob’ may represent a chronic patient, who has a long term health condition, with various needs, meaning that he uses the service regularly and often. The ‘Bob’ character would be formed using data from users who share similar service needs and patterns. Please ask me if you have any questions.

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187

Questionnaire

This questionnaire establishes some simple but key information, in order to create some initial service user profiles If any questions are not applicable, please leave them blank. If you cannot remember some of the answers, an approximate guess if fine.

How often (for personal health reasons) do you visit an NHS Dentist?

Infrequent, regular (not often, established time patterns) Once a year or less, at a set time

Please place a mark in one of the boxes

Infrequent, irregular (not often, no established time patterns) Once a year or less, at random times

Name

Frequent, irregular (often, no established time patterns) Once every few months or more, at random times

Age Occupation

Frequent, regular (often, established time patterns) Once every few months or more, at set times

Place of residence Local GP Surgery name

Or if you feel that your usage pattern doesnâ&#x20AC;&#x2122;t fit into any of these options, please describe in your own words:

Local Hospital name

When was the last time (for personal health reasons) you used the following NHS services? eg. last month

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Dentist

Optician

In general terms, what are the reasons for your visits? A&E

Hospital

Other, please state

Supporting material

ie. check-ups, repeat prescriptions, tests

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189

How often (for personal health reasons) do you visit an NHS GP?

Infrequent, regular (not often, established time patterns) Once a year or less, at a set time

How often (for personal health reasons) do you visit an NHS A&E?

Infrequent, regular (not often, established time patterns) Once a year or less, at a set time

Please place a mark in one of the boxes

Infrequent, irregular (not often, no established time patterns) Once a year or less, at random times

Please place a mark in one of the boxes

Infrequent, irregular (not often, no established time patterns) Once a year or less, at random times

Frequent, irregular (often, no established time patterns) Once every few months or more, at random times

Frequent, regular (often, established time patterns) Once every few months or more, at set times

Or if you feel that your usage pattern doesnâ&#x20AC;&#x2122;t fit into any of these options, please describe in your own words:

In general terms, what are the reasons for your visits?

ie. check-ups, repeat prescriptions, tests

190

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191

How often (for personal health reasons) do you visit an NHS Hospital?

Infrequent, regular (not often, established time patterns) Once a year or less, at a set time

Please place a mark in one of the boxes

Infrequent, irregular (not often, no established time patterns) Once a year or less, at random times

How often (for personal health reasons) do you visit an NHS Other (clinic etc)? Please place a mark in one of the boxes

Infrequent, regular (not often, established time patterns) Once a year or less, at a set time

Infrequent, irregular (not often, no established time patterns) Once a year or less, at random times

Frequent, irregular (often, no established time patterns) Once every few months or more, at random times

Frequent, regular (often, established time patterns) Once every few months or more, at set times

Or if you feel that your usage pattern doesnâ&#x20AC;&#x2122;t fit into any of these options, please describe in your own words:

In general terms, what are the reasons for your visits?

ie. check-ups, repeat prescriptions, tests

How would you describe your general state of health?

Do you have any long term health conditions? If yes, please briefly describe

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Supporting material

Supporting material Thank you for completing the questionnaire.

193

194 Supporting material ..................................................................................................................

.................................................................................................................. A&E

.................................................................................................................. Outpatient elective care (planned Hospital visit without admission)

Inpatient elective care (planned Hospital admission)

Acute care services

..................................................................................................................

.................................................................................................................. Minor Injuries Unit

.................................................................................................................. NHS Direct

.................................................................................................................. NHS Walk-in-Centres

.................................................................................................................. Community Pharmacies

.................................................................................................................. NHS Opticians

.................................................................................................................. NHS Dental practices

GP Practices

Primary care services

On average, how often each year do you use the following services?

..................................................................................................................

Please write a short description below, detailing any activities contributing to, and attitudes towards personal health. (Any exercise you do, how conscious you are of food and alcohol consumption, if you smoke and so on.)

Results to value within services:

Least valued

Supporting material

Profile 1 2 3

Most valued Convenience Word of Mouth Past experience Past experience

Outcomes Outcomes Price

Past experience Convenience Personalisation

Price Price Outcomes

Personalisation Personalisation Convenience

Least valued Word of Mouth

Profile 4 5 6

Most valued Outcomes Outcomes Past experience Outcomes

Personalisation Price Price

Past experience Past experience Word of Mouth Convenience

Convenience Personalisation Personalisation

Word of Mouth Convenience

Price Word of Mouth

Word of Mouth

195

Results to value within the health service:

Profile

Most valued

Outcomes

Past experience

Most valued

Outcomes Cost

Outcomes

Convenience

Outcomes

Continuity of care

Participation Information

Manner of staff

Convenience

Manner of staff

Price

Participation Convenience Choice and range

Past experience

Personalisation

Information Manner of staff

Cost

Personalisation

Convenience

Environment

Least valued

Word of Mouth

Information Continuity of care

Choice and range Cost

Convenience

Participation Outcomes Environment

Choice and range

Continuity of care

Least valued

Profile

Most valued

Outcomes

Outcomes Manner of staff

As a means of identifying trends, below is a list of the average answers from most to least valued:

Continuity of care Manner of staff Cost

Cost

Past experience and Outcomes

Information Participation

Manner of staff Choice and range

Convenience Choice and range Environment

Information Continuity of care

Summary of results

Convenience Particpation Cost

(Joint) 1st

196

2nd

Price

3rd

Personalisation

4th

Convenience

5th

Word of Mouth

Information Continuity of care

Convenience Environment Least valued

Supporting material

Environment

Choice and range Participation

Supporting material

197

Results to guessing the costs of services:

D Profile

Profile

Most valued

Outcomes

TV license fee

Continuity of care

Information Cost

Choice and range Manner of staff Manner of staff Continuity of care Participation Choice and range Cost Convenience Convenience Participation Information Least valued

Environment Environment

E 4

n/a

Cinema ticket

Exercise 5 MOT Service and

—

Flight ticket + — Could people guess how much NHS treatments/procedures cost? Restaurant dinner Participants were asked to guess roughly how much NHS treatments Hair cut and procedures cost the service to deliver:

—

University fees Appendecomy - removal of the appendix, in patient hospital stay

Hip fracture Blood test Ultrasound scan - lasting 20 minutes+ Profile 6 7

Lung transplant

Summary of results The average answers from most to least valued:

TV license fee- removal ofn/a — Tonsillectomy the tonsils, in patient hospital stay Cinema ticket MRI scan - magnetic resonance imaging scan Service and MOT +

1st

Effective treatment and successful outcomes

Flight ticket + are based + The costs for these treatments and procedures on amounts published by the Department of Health. (REF HERE) Restaurant dinner This test serves as an interesting comparison to the previous Hair cutwhich looked at accuracy around known services.— exercise

(Joint) 2nd

Continuity of care ‘Cost’ was placed the most times here

(Joint) 3rd

Manner of staff and physician Choice and range of services available

(Joint) 4th

Participation and representation in decision making Comprehensive information Convenience and ease of access

University fees — — The results were judged underestimated or overestimated if the guess was made outside of a 20% margin either above or below the correct cost.

Physical environment and surroundings

Key:

5th

— + n/a

198

Supporting material

Underestimated Overestimated Within 20% margin No results collected - exercise not carried out

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199

Results to guessing the costs of treatments:

Discussing value transcripts: What is value?

Profile

Appendectomy

—

n/a

Hip fracture

—

Exercise 5 Blood test

+ —

—

Lung transplant — + Participants were asked to guess roughly how much NHS treatments and procedures cost the service Tonsillectomy —to deliver:

Hip fracture Blood test

Lung transplant

Appendectomy + patient hospital — Tonsillectomy - removal ofn/a the tonsils, in stay Hip fracture — — MRI scan - magnetic resonance imaging scan Blood test +

Ultrasound + are based + The costs for these treatments and procedures on amounts published by the Department of Health. (REF HERE) Lung transplant — — This test serves as an interesting comparison to the previous Tonsillectomy + exercise which looked at accuracy around known services.— MRI scan + + The results were judged underestimated or overestimated if the guess was made outside of a 20% margin either above or below the correct cost. Key: — + n/a

200

Underestimated Overestimated Within 20% margin No results collected - exercise not carried out

Supporting material

“There’s the core thing, there’s the product you’re going to get… and there’s also the peripheral things around it… the non-money” “I think quite often you appreciate the thought behind it… The things that I like most are sometimes things which the children have done… the fact that they’ve bothered to go out and get you something, you appreciate the thought behind that.”

— —

MRI scan Appendecomy - removal of the appendix, in patient hospital stay

Ultrasound scan - lasting 20 minutes+ Profile 6 7

5 —

Ultrasound — + Could people guess how much NHS treatments/procedures cost?

“We put our levels of what we consider value, we change them, according to circumstance…” “It’s a complex algorithm for what we you consider something to have value.” “If I over pay on something, and then get it and think that I’ve … been conned into overpaying on something – the level of frustration I feel has no… almost no relationship to the amount of money involved; I can feel deeply annoyed.” “You can go cheap and really think that cheap is poor value for money, you really don’t get what you want.” “It’s defining what you want… if you don’t define that yourself, what you want…” “And sometimes you find out what you want when you bought it… it’s only when you test it that you find out whether or not it actually satisfies what you want and then the judgement kicks back in terms of all the other things, in terms of cost…” (on services) “I think in that respect we are much more judgemental on the service side of it, in the respect that, when you’re buying goods, you don’t always know exactly what is an appropriate price to pay for a certain goods… But service - we’ve got a much clearer view of what level of service we expect and will accept and that again is different with each person.” “If you went to see a Doctor, you didn’t necessarily expect the doctor to have social skills. If he had medical skills that was almost sufficient… these days in terms of how the doctor treats you is almost, in terms of treating you as a human being, is almost as

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201

important as whether or not he has medical competence.” “Are we more concerned by the façade?” “The important thing when dealing with a doctor is that he’s competent at what he does, has in depth knowledge, can correctly diagnose and if he does all of that, and he’s a bit of a miserable wotsit… then in a way, at some level that doesn’t really matter.” “It’s the core bit that’s important, but we tend to value… almost the veneer more than the core.” “I think it would change my opinion of the person” “I think it would make me feel guilty” “You might be interested to find out why it’s worth a lot of money” When have you experience good/bad value for money? Ocado home delivery Very good after operation – problems with getting around, lifting etc - order online, “do it from the comfort of my own home” - very convenient (core service) - ease of internet website - personalisation “I felt like ‘oh they know me!’” - They fell down later by charging a delivery fee - Sharing service (appealing to ‘green’ side) When your car is due for MOT/Service - reminder service - “I kind of value the fact that they let me know” - “it’s that personal touch, that I value” Restaurant eating 2 kinds Pizza express etc - no unexpected surprises - “you know precisely what you’re going to get”

202

Supporting material

- “it’s quite reasonably good value for money… you think” - “there’s a comfort factor about when you go to somewhere that, it’s going to give you precisely what you want” - “Immediately when I start paying more, my expectation starts to rapidly escalate” - (on Michelin start restaurants) “The setting is lovely, the surroundings are nice, the service is attentive… everything is timed nicely… you’re left a reasonable amount of time… clearly every aspect has been thought through. The food looks good and tastes nice and is interesting.” Riverford boxes - “Sometimes I think it’s not good value, because of coming home late, I don’t always have time to cook things… I end up throwing things away… I don’t think it’s Riverfords fault but it’s the way we use them.” - “The more they could do to perhaps find out more about you and tailor what they provide to the particular situation that you’re in.” - “There’s a product; you could apapt yourself to be more adapted to that product, or … the people providing the product could actually find out more about you… if they understand you, they can potentially adapt their product more to your needs.” Chairs - - - -

legs were different colours prompt response going beyond took away both chairs (and ensured that legs matched)

Working – thought I was being paid a good wage, found out that it wasn’t that good. Made me feel less valued. “In anything where you’re dealing with sales people you don’t feel like you’re getting good value, because you’re always distrusting the end result” “I feel more compelled to trust kwik fit because they feel more like a shop”

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203

“Nothing feels good value anymore” “The cost makes us go there, the service makes us stay there and recommend it” “With something like a car… you need a very good service. Because you need to trust that you can get back in your car” When have you experience good/bad value for money within the NHS? Broken leg/ruptured tendon Would turn up at 9am along with about 30 other people, then move through the first process, moving from process to process with lots of other people, lasting 3-3 and half hour visit. Final experience was with a medical professional for 5 minutes. “It was quite clear, that the way the service was organised… benefited the medical staff and you were just… an ancillary to be moved around at their convenience, so that none of their processes ever had to wait for you, you were always there, ready and waiting for them” Went back to same fracture clinic after a number of years. People would have timed spaced appointments instead of a group. “At least they were trying to adapt the service, so that... they were at least making some attempt to adapt your experience to be reasonable for you”. Smear tests Have to ring up at inconvenient times (for patient) Online process is long winded But they do have a reminder service When leg was broken Heading to the hospital, the ambulance had an emergency call, so the vehicle was getting to the person, whilst I was being shoved around on a wheeled trolley in the back. A pneumatic bandage was removed from the leg and another was put on – very painful (when moving from one ambulance to another).

204

Supporting material

Recent knee problem Getting an appointment same day, straight away X-rays were promptly offered Quick results “It wasn’t like it used to be… you’d have to wait a couple of weeks for this, a couple of weeks for that… I think it’s definitely improved…”

“It depends on how ill you are” “If you’ve waited a long time, and even if you are in extreme discomfort… if you have a positive outcome; in other words they’re able to tell you what’s wrong… then it was worth it. If however, through no fault of anybody, they’re unable to tell what’s wrong with you, and you’ve had the same experience, you come away feeling very down – it’s quite depressing.” “It’s like entering a process that you don’t really understand… you get to stage four (final)… in between your faced with frustration and being aware of the time you are spending.” Learn to be more patient. “Patients probably are depressed to being irritable to being angry… you fall into one of those categories and it’s difficult to stay focused and positive…” “In the early stages of my motor accident injuries, I felt like I was being pushed pillar to post, each time with an expectation. And because you’re seeing someone new, they may be able to solve. And because you’re going along a chain of people but in an upward direction… the number of people you see wears you down… you’re expectations drop as time goes on. And you kind of get a little bit upset… with what you perceive the knowledge of the specialist is. You feel, if you’re ill, they’ve done their training, they specialise in a particular subject. If you go to them, they should be able to diagnose what’s wrong, and help you. But that’s not always the case. That’s a hard lesson that one.”

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205

Broke arm. NHS plastered arm. Private service is quicker. NHS misdiagnosed arm – private doctor said it’s not broken, NHS said it was etc. Not given enough time in A&E to assess. By going private it was much quicker.

needed, and then I went home again and I was better. That felt like good value. He was… I liked his manner, it was quite business manner… and it was out of hours, so you feel like they’re doing more of a favour.”

You use NHS because you have to – would always choose to go private. quicker, better surroundings, take time to talk to you, receptionists are nicer. “You actually feel that they care”

“The thing I’ve found, is that private, because you’re paying for it, they will give you anything you need, as and when you need it…. Whereas you go NHS, and it seems more that they … they would prefer to just listen to what you’re symptoms are, almost as a first point. And the process just takes longer.”

Pregnancy – 2nd birth – discharged too early. “shunted out”

“I would in a heartbeat go back to Private as soon as I needed more urgent treatment”

Pre and post natal care very good. “I’d phone that morning and they were round within a couple of hours” “That was a good experience”

“There’s more of a willingness, because cost doesn’t matter. They’ll just do it there and then for you Private. Whereas, quite understandably, NHS they won’t just do it, which, yeah I get that. And it is going down hill to be fair… there’s an IBD nurse that I see… and she used to work full time… you could get hold of her whenever you wanted. And she now… she has 3 hourly slots in a week… she’s clearly so busy that it takes 10 minutes to get through to her… you don’t even get a voicemail option.”

“They took the time to teach you to feed” “Private feels like they’re offering you a service, the NHS feels like they’re not” “If you compare where you stay overnight; NHS versus private and their worlds apart. And yes, the NHS you pay nothing for, Private you pay £100+ a night… but you get your own room, you get your own toilet, your own bathroom, ensuite, it’s like a hotel room quite frankly… Lunch you get all your food provided… it’s nice food, you actually get a menu to select your food from, all that kind of stuff, which the NHS is just…” Very good experiences with NHS concerning childrens care. Mentioned that they wouldn’t bother taking children to private because the NHS is so good. Also spoke of donating toys and books mid conversation - showing genuine appreciation – willingness for reciprocity. “When I was vomiting, I went in, they gave me exactly what I

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“But then a good experience I’m having, is the medication I’m on is costing £140 a month… and my doctors pay for that… so from that point of view, I’m getting a good service, for something, that’s obviously costing a lot of money” “And the Doctors down there are very good, you do feel like they take the time, and they do refer you on… you do feel like you’re being taken seriously”. “As for value for money, it’s very difficult for us to respond, because we don’t actually pay… we’ve done our paying… you don’t seem to get value for money in your younger years but now, we are certainly reaping the benefits” “So really, if you consider how much we pay in, and now taking into account, the cost of living rises, that must be good value”

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“When you’re ill, you don’t have to worry about the expenditure of it, that’s the big value in it.” “The value we got for mum was fantastic; District nurse in 3 times a week, bandages, fantastic” “There’s a degree of luck comes into this, because I’m sure that most people round here have had some, what they would say was poor experiences, with the National Health Service. But generally, yeah, they’re pretty good” “That’s satisfaction” “I think the dissatisfaction that a lot of people have, is with the doctors these days. Where you ring up on Monday and they say we can’t see you until Friday. And you say, well I might be dead by then… I’ve got a friend who’s got about 11 doctors in his practice, and he can never see the same doctor twice.” Discussion around continuity of care. (or lack of!) Nurses not from this Country – communication problems. “I think back to a time when you’d call a doctor out at night and your usual doctor came to see you… we see this in so many other spheres, the quality of service is dropping, because so many more people want to use them” Talking about National health records. “That would cost money. And is it money better spent on treatments or equipment rather than trying to get over to people, the cost of what they’re receiving, what would be the benefit of knowing how much it’s costing?” “It might put people off asking for the service”… “It’s like having to pay for your Dentist… it’s too expensive… that’s not value for money – Dentists. You go to three different Dentists and they all charge different amounts”.

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“There is a theory, that if you have to pay for something, you value it more highly than if you’re getting it for free. So who’s going to win out of all this?” “When it started, it was an excellent thing and saved many lives. Especially people in poverty. Today my feeling of it is that it’s a bit abused… had they got to pay for that, they wouldn’t go. They would either treat themselves, or maybe wait… but like many things you get given free, the system gets abused.” Flexibility around private health care. “… it was absolutely spotless. She had a chap come in and he’d scrub the place… every single day… I think cleanliness in the NHS has got an awful long way to go.” Wanting Matrons back. Nurses out smoking, shopping in their uniform. “The amount of equipment that gets thrown away after use… “ waste “… save money in the admin, in the office… maybe that should be looked into.” ‘The NHS has got too many managers” “I think they would respect it more… it might put some people off. They see a relationship to the money they’d paid in. But I rather dread to think what might happen because there’d be another army of bureaucrats to produce the information”. “You wouldn’t get the complaints so much. You know, if they could see how much it cost” Prescription items that are cheaper to just buy in the chemist. Doctors prescribing different drugs that are cheaper – patients not knowing / being informed as to these changes – not convinced that

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drugs are the same.

Feedback on initial prototypes:

“I think there’s a fascinating tension that’s been highlighted between the doctor who wants to give you the best and the fact that it’s going to impinge on his budget.”

“Something that said ‘Thank you for choosing the NHS’, would probably make me want to screw it up and throw it at somebody… because it’s not a choice”

“And ‘You’re total balance for this year is…’ I’d probably feel slightly annoyed by that as well… what does that mean?... I can spend the National Health Service as far as I want to go can’t I?... That would annoy me” “The bit about ‘Total tax contribution…Total service usage’…yeah, that’s quite interesting”. “But it might make you feel ‘gosh, if that was less, gosh, having paid in that I need to get sicker to make the most of it!” “No, that would just make me feel vaguely smug… it wouldn’t annoy me that I’d paid more money than I’d had out. I’d just sort of think… ‘I’m more healthy than most people’”. “But there are some jobs, where it’s known that people take their sick leave entitlement, as an entitlement… and I don’t know whether something like that would have a similar effect”. Statistic and health advice gave a competitive element – something to beat. Saw the contributions and health advice as a set of scales. One side is the amount you’ve used, the other is the prognosis. Ie. The amount of advice will never bring down the usage? “They’re spending your contributions, because you are not. So you’re paying for their lifestyle… But then you feel that things have balanced out, you don’t feel begrudging about the amount of money you’re paying. Because you’ve then got value. You may say, I was only 1 in 3 or 4 years, therefore I then got the value that I paid in my contributions.” “That implies a personal level. That is purely a statement of accounts… You can’t see from that how many people you’re going to

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use, so you should marry the two up.”

E-mail conversation between Dr Vijay Nayar and myself

“People with a long term illness, that it’s not going to get better – this is no good to them. In fact it might be damaging.”

Sent 18 October

“I don’t like this – this is ridiculous” (referring to ‘choosing’) “I quite like the idea of a reminder service, because that probably saves them money… that would be useful and takes the onus away from the individual to try to remember…” “I don’t really understand this very well (icons)” “I don’t see the value in… (receipt), your last visit has cost this, only because I think most people wouldn’t take any notice of it and it would become something that was ‘oh they’ve handed this to me, are they trying to guilt me?’ I don’t think I’d feel particularly happy about each time I’d been to the Doctors, getting a statement of what my visit cost. I also find the text message… a bit odd I think… but what I do really like is the yearly statement, and I think that’s a good idea, because you’d get that at the end of the year… it just shows you how much you’ve used it and what costs, and not necessarily with the tax bit because, I don’t know how much value that would add to me as a person.” “I don’t think it should be displayed as your yearly statement, it’s more of an advisory, or … even if it’s a built as a campaign of ‘The NHS/Government want you to realise how much the NHS is actually giving to … you’re gaining out of the NHS as a service and as such we’re going to start providing you with an annual statement. If it’s done in the right way… there would need to be more than just receive a statement” “If it were done too regularly, it would cause people to just not care, because (is it a guilt thing)…”

(Some detail excluded) I hope you don’t mind me contacting you for some pointers in terms of information that I’m unable to confirm for myself. I’ve had some trouble in finding exact requirements of diabetes patients. Obviously each patient uses different parts of the service, but to get an idea of an average diabetes patient (who isn’t using a pump), would the following be correct? In terms of consumables: Insulin injections Blood sugar test strips Any medication, ie. statins Services: GP appointments Consultations with a diabetes specialist nurse eye screenings flu jab and vaccinations blood test, blood pressure test, urine tests, cholesterol check legs and feet checked weight checks Also, in terms of cost, I don’t know if it’s possible but would you be able to give me a rough idea of prices for things like GP appointments? All the best, Amy

“Even if it looks like one (a bill)” It would be a problem.

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Reply from Vijay 23 October

E-mail conversation between a diabetic patient and myself

(Some detail excluded) with regard to diabetes you need to distinguish between those who are just diet controlled, on tablets or on insulin (+/- tablets). Their costs will vary. Test strips are mainly for those on insulin. You are right that most will be on statins regardless of their treatment. Generally diabetics who are well controlled require a blood and urine check and interim appt at 6/12 (BP,wt and check results) followed by an annual review 6/12 later with repeat blood/urine tests BP/wt but also foot check. The interim is usually just with a nurse. Annual is with a nurse and doctor. They all need annual flu jabs (?£10). Eye screening should be annual (?£20)-”diabetic retinopathy screening” if you wish to research this.

Sent 31 October

Cost of a GP consultation is around £36 and £10 for nurse (source from a dementia document and Curtis 2009): http://www.nice.org.uk/nicemedia/live/13076/50058/50058.pdf This also has some costs for tests Also Kings fund has some data. hope that helps.

(Some detail excluded) To give you a bit of background; the project that I am working on at the moment is looking at ways in which to communicate a sense of value to NHS patients. I have chosen to focus one of the outcomes on the care provided for diabetic patients as it seems to follow a fairly set pattern. I have some questions about how you keep track of your appointments and any supplies you might need. 1. In terms of keeping track of appointments; is there a reminder service, or are you given anything that sets out when you should be having certain check-ups? 2. If you are using anything in the way of medical supplies like blood sugar test strips or medication - do you keep a note of when you think you might need to get some more or is it a case of simply getting some when you’ve almost run out? 3. Finally, if there were something that reminded you when you should be having these checks etc, would this be helpful in anyway? Or do you find things manageable as they are?

kr Vijay

Let me know if you’d like further clarification on anything if it’s not clear. Best wishes, Amy

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Reply 1 November

Full feedback Personal Annual Health Report

(Some detail excluded) In reply to your questions:-

Co-design participants:

1. Our practice has a doctor and nurse who specialise in diabetic patients and they hold diabetic clinics which I attend every 6 months to monitor progress. The surgery issue a reminder letter shortly before the appointment inviting me to attend. 2. I keep a record of my repeat prescriptions and at the start of each year make a note in my office diary of the dates every 4 weeks throughout the year when they are due. I then collect all the items on the prescription at one time. 3. I think that because I operate an office diary based system for client appointments on a daily basis this lends itself to monitoring other personal appointments. So I find the system I have at present works well for me in my present circumstances.

“it makes sense, I think everyone in the practice should have one” “I thought it was very well presented and is very clear to understand. I like the fact it tells you how much the appointments are and that they are covered. It makes you think about those missed appointments because I presume the tax payer still pays for missed appointments?? I like your recommended health plan, because I don’t think you would think to have your iron checked without the plan informing you. I also found it interesting how many patients ‘my’ doctor has and the fact that I book appointments on the busiest day would make me want to change my day unless it was an emergency. I felt the booklet would be beneficial and make patients think about appointments and treatment costs before abusing the system. Don’t know if this is helpful or not, let me know if you would like any more thoughts.” If you were sent such a booklet in the post next moth, what would your initial reactions be? Is the information presented sensitively or is there anything that makes you feel angry or confused? I would be interested, but also wonder how much it cost to produce this. I liked seeing the costs for different appointments/services and the information on the doctors. The information on the pattern of appointments was interesting. The number to re-schedule was helpfully placed. I would prefer the appointments timeline to run from left to right, earlier to later. It would be useful as you would build up a record you could refer to when asked by insurance companies. I would feel confused as to why this information was being sent to me, but would find it an interesting read. I would be concerned as to the ease of my personal information getting into the ‘wrong hands’. I would hope there was no ‘surprise’ to receive this, ie. there has been previous communications of why this was beings sent.

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Interesting to see the information. Not sure if the details of missed appointments necessary, as there may have been good reason.

more pro-active.

My reaction is a positive one: • It’s about the right length – too long a document would make me lose interest. • It’s clearly set out and easy to absorb – I like the clear division between the general and the specific. • It provides information about me – therefore I’m interested. • It seeks to inform and not (blatantly) preach. • It provides historical data (interesting) and advice (more interesting).

Is there anything you think is missing? What would make this more relevant/interesting to you?

Do you feel that this kind of information represents the ‘value for money’ delivered by the NHS? I think this gives you an idea of the costs involved. I’m not sure if what you get is ‘good value’ or how you know without some comparisons. I think you want to know you will get what you need when you need it. I would question the cost of producing such information when the NHS is facing cuts. I am unsure if the information shows value for money; it gives me cost but I am unsure where I would feel I am getting value for money with no cost or spending for comparisons. Not really, there isn’t enough focus on how much this would cost the NHS, other than prescription costs. There needs to be a comparison. Harder to answer this. It tells me that I’ve had a certain amount back in return for the tax I’ve paid. It sensitises me to the actual monetary cost of my personal health care. However, I might look at this and think that I’ve paid out much more than I’ve received. I don’t think this way about my house insurance and it may be useful to remind me slightly more strongly about the safety net of emergency services and operations that is there when I need it. The other reaction I have is to think what a reactive service the NHS is and wish it were a bit

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This seems to me to be fairly complete. Would you have to do web links for someone with a particular condition to a support group/ charity? Some random thoughts and what I might like to see: • P5: What are the future plans for the NHS? Is anything planned for my area? • P6: Some comparison this year / last year indicating the growing demand and output? Number of emergency procedures / major operations carried out in the NHS? (But I appreciate too much information would be a turn-off) • P7: What do I do out of hours? • P9/10: What services are available in my area? What do they do? • P14: What do missed appointments cost the practice each year? (Most graphs I see time increment to the right!) • P15: When is the practice quietest (i.e. the best time to come)? • P19: Like the idea of being told how to save money. • P20/21: What should I do about this advice? Who should I contact, when? • P22 (not numbered): Perhaps direct me to something on the internet that provides me advice on healthy living – ideally tailored to my age, gender, weight, height, medical history, family medical history, etc. Do such things exist? Any other comments? Would there be an e-mail alternative? I would be interested to receive this sort of information but it also seems quite ‘Big Brother’ish.

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I thought the health plan was useful as well as advice on prepayment. The information on pre-payment was useful as this is not something everyone is generally aware of. I would still be a little concerned of personal information falling into the wrong hands. What are the specific outcomes/reactions you seek from the reader by producing this document? You might list these and ask us to score them. What is the cost/benefit of producing this document? Have you estimated either? Can you make a case that the benefits outweigh the costs? Any estimate of benefits would be speculative at this stage. Do you envisage a pilot project to refine the document and establish the benefits? I thought it was very well presented and is very clear to understand. I like the fact it tells you how much the appointments are and that they are covered. It makes you think about those missed appointments because I presume the tax payer still pays for missed appointments?? I like your recommended health plan, because I donâ&#x20AC;&#x2122;t think you would think to have your iron checked without the plan informing you. I also found it interesting how many patients â&#x20AC;&#x2DC;myâ&#x20AC;&#x2122; doctor has and the fact that I book appointments on the busiest day would make me want to change my day unless it was an emergency. I felt the booklet would be beneficial and make patients think about appointments and treatment costs before abusing the system

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Feedback from Daniel Steenstra:

Hi Amy I must say that I am really impressed with your work - it should be implemented straight away as is. Only 2 comments : - should include hospital and other NHS care (I understand that this does not apply in your example) - I imagined to receive this as a booklet - 13 pages means that you have space left for adverts (anti smoking etc) What I liked in particular was the integration of general NHS information and specific information for this patient. What has feedback from the field been so far - GPs? I strongly feel that this should be trialled - do you have contacts? otherwise I have a contact with a director of public health in a PCT and a GP Commissioning Group. Do let me know if and how you would like to proceed. Kind regards Daniel Steenstra Royal Academy of Engineering Visiting Professor in Innovation

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Hi Amy

Full feedback from Vijay Nayar:

Simon and I are just on our way back from a visit to France meeting with research partners.

I think that’s really good. If we could easily produce a report for patients in that format I’m sure that would achieve the objectives that you set out. Not much to change except the average GP list size is around 1800 patients so your numbers are a little on the low side.

Another suggestion is to include local health data - I.e. % of GP surgery patients also have high blood pressure; or total distribution between for example lung disease, heart, musculo-skeletal, chronic conditions (diabetes) etc. It needs testing with real patients to see how much information they can process and to assess impact on their behaviour. I believe that you are attending our 1 Dec event; it would be good if we could present your work, maybe as hand-outs. Please let me know if there’s anything else I can do. Cheers Daniel

kr vijay Full feedback from Simon Potter: Hi Amy, I really like this. Definitely a case where “less is more”. The acknowledgment that appointments had been missed is very powerful and would certainly interest people whose time was wasted. The way the financial summary is presented is really useful too. Did you deliberately not put in totals though? The only critique I would make is about the colours and the strength of the graphics. For my taste, the report needs just one more colour. I know why you have set it up like you have, but to my eye there is just something missing. The other point is the graphics. May be the appointments graph could be a little stronger. Really, really minor things. Congratulations. Best wishes, Simon

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Full feedback on Diabetes Appointment Planner From diabetic patient 1 I think the iPhone/smartphone is a great idea. If I wasn’t office based and didn’t operate a diary I’m sure that appointments could easily be overlooked. Anything that helped as a reminder would be welcome to me and if it helped reduce missed appointments would save medical costs. 1. How well do you think it meets the objective of ‘informing patients of the cost of their care?’ I’m not sure about the part about informing patients of the cost but 2. Does the way in which the cost is presented, make you feel angry, annoyed or negative in any way? I wouldn’t feel negative about that in any way and I feel that 3. Do you think that it is important that all NHS patients should understand the cost of their care? It would be interesting to know the cost rather it being important that I understand the cost of that care.

From diabetic patient 2

Do you think that it is important for all NHS patients to understand the cost of the care that we receive? Whilst it is of interest, the NHS promotes itself on providing free care to patients with chronic diseases. A diabetic cannot survive without medication, or good control of their diabetes, without certain equipment e.g. an insulin pump, blood glucose machine and test strips and urine/ketone test strips, as well as the battery tests that you have focused upon. I feel that knowing the costs of all of my equiptment, medication, tests etc will make me feel guilty for using up so much money of the NHS, particulaly duing the current recession and cuts to NHS funding. It also leads me to thinking, with worry, about what would happen if funding for diabetes were to be reduced or taken away and how this would impact on my quality of life. The outcome has been designed as means of informing patients of the cost of their care; how well do you feel that this outcome meets that objective? The cost if care (the flu jab @ £10) was indictaed but I don’t think it was the prevalent feature of the app. I feel that the way it allowed the patient to manage their diabetes was the most effective detail Does the way in which the cost is presented make you feel angry, frustrated or negative in some other way? As mentioned above it facilitates a sense of guilt at costing the NHS so much money, depresssion at the realisation of this as well as the reinforcement that you are unwell and require on-going care and support. Would this application (or an online version) be of any use to you? If not, why? It would be of use to help manage my diabetes

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From diabetic patient 3 Do you think that it is important for all NHS patients to understand the cost of the care that we receive? It’s interesting, but you need to remember that the way in which this information is presented can trigger many depressive thoughts for type one diabetes (who are at a much greater risk of depression than other patients). If it’s presented as “you’re a bit of a waste, aren’t you, then?”, there’s often a hesitation created in type one patients in terms of asking for appropriate treatment. The outcome has been designed as means of informing patients of the cost of their care; how well do you feel that this outcome meets that objective? Not really. I thought it was all about keeping track of care and leaned towards getting appropriate treatment. Does the way in which the cost is presented make you feel angry, frustrated or negative in some other way? How much does it cost you to breathe? Annoyed. See my comments below. Would this application (or an online version) be of any use to you? If not, why? This app could get administratively very messy. For instance, I’m always having to sort things out between my primary and secondary care (i.e. between the GPs and the specialists) - and unless the information was co-ordinated across both, you’ll have people being told they have to have a flu jab when they’ve already had one; or eye tests; or annual reviews. Any other comments or initial reactions? Well, I’m annoyed that the point of this app is designed to let me know what the cost of care is. Thanks for making me feel like a leaden weight on society, all because of a condition (type one diabetes) that was not caused by anything ‘wrong’ I did. And what’s the point even of making type two diabetes sufferers (who DID cause their own condition) feel like money drains - they’ve got it now, so how are we going to treat it? Really annoyed, because I’d like to

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think that I contribute to society rather than cause it to raise the retirement age to pay for my health.

From diabetic patient 4 Do you think that it is important for all NHS patients to understand the cost of the care that we receive? Yes, this would make patients take their appointments seriously, avoiding cancellations and freeing up more NHS time and money. I would also be more aware of my prescription costs and not wasting medication etc The outcome has been designed as means of informing patients of the cost of their care; how well do you feel that this outcome meets that objective? Presuming that each appointment would show the cost as in the flu jab then yes the outcome meets that objective Does the way in which the cost is presented make you feel angry, frustrated or negative in some other way? No, it is written clearly below the ‘free’ cost to the patient as information rather than a negative comment. Would this application (or an online version) be of any use to you? If not, why? No -I do not have an i phone and am not very technical!! Any other comments or initial reactions? In this day and age most people (esp young teenagers who are less likely to attend appts) probably do have i-phones and therefore it would be beneficial to them - it seems easy to use and therefore I would probably use it if I had one.

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From diabetic patient 5 Do you think that it is important for all NHS patients to understand the cost of the care that we receive? Might make patients pay more attention to the advice given and meds supplied, if they know how much it costs The outcome has been designed as means of informing patients of the cost of their care; how well do you feel that this outcome meets that objective? Its a start but, more information cant but help Does the way in which the cost is presented make you feel angry, frustrated or negative in some other way? No grateful that I don’t have to pay Would this application (or an online version) be of any use to you? If not, why? It would be of use as a reminder and planner - costs I don’t know how much help would be to myself, if any

From diabetic patient 6 Do you think that it is important for all NHS patients to understand the cost of the care that we receive? No - It would worry some patients and then they would not go for appointments because of the costs - especially the older ones. The outcome has been designed as means of informing patients of the cost of their care; how well do you feel that this outcome meets that objective? See above - You will scare too many people. Does the way in which the cost is presented make you feel angry, frustrated or negative in some other way? See above - you will scare too many elderly people.

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Would this application (or an online version) be of any use to you? If not, why? No - I use a diary and it has worked for me for 42years so far. I do not just have diabetic appointments! It is a waste of time and another thing to do which is wasteful. Any other comments or initial reactions? See above - seems to be re-inventing the wheel. From diabetic patient 7 Do you think that it is important for all NHS patients to understand the cost of the care that we receive? I presume you mean the care that THEY receive? No. It isn’t relevant. Constantly being nagged about NHS costs is the last thing a new (or any patient) diabetic needs, and is unproductive. The outcome has been designed as means of informing patients of the cost of their care; how well do you feel that this outcome meets that objective? Adequately Does the way in which the cost is presented make you feel angry, frustrated or negative in some other way? To be quite frank, Angry. See above answer 2. Would this application (or an online version) be of any use to you? If not, why? Not really. I only attend the clinic once a year. During this period the appointment will probably have been cancelled or rescheduled by KHA anyway. See example in 6. below. Any other comments or initial reactions? This app can only work if it is supported by, and in sync with, the hospital’s infrastructure. Example: I was recently sent an automated voice message on my mobile phone to remind me that my appointment was on the following Tuesday at 8.30 am. Fortunately I bothered to listen properly and noted that it should

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have been 1.30 pm, therefore someone had made a mistake. I called the hospital and was told that the consultant had decided to discontinue afternoon sessions six months ago. Nobody told me this, and I cannot get to the hospital that early in the morning by public transport. So that appointment was effectively wasted - after Iâ&#x20AC;&#x2122;d booked the day off and arranged cover at work. Consequently Iâ&#x20AC;&#x2122;ve now got to wait till March for another one. I hope this illustrates my point: i.e. that the app would potentially be supplying incorrect information to the patient. I think the idea of making people aware of the cost of their treatment is frankly a non-starter; your efforts could be much better spent on ways of making the patient feel better.

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Published 23rd November 2011 All content owned by Amy Ricketts.