The healthmatters blog; commentary, observation and review
Major new book tackling if a given treatment is really able to do what you want it to do:
Ending Medical Reversal, Improving Outcomes, Saving Lives, Vinayak K. Prasad, MD, MPH, and Adam S. Cifu, MD
We expect medicine to progress in an orderly fashion, with good medical practices being replaced by better ones. But some tests and therapies are discontinued because they are found to be worse, or at least no better, than what they replaced. Medications like Vioxx and procedures such as vertebroplasty for back pain caused by compression fractures are among the medical “advances” that turned out to be dangerous or useless. What Dr. Vinayak K. Prasad and Dr. Adam S. Cifu call medical reversal happens when doctors start using a medication, procedure, or diagnostic tool without a robust evidence base and then stop using it when it is found not to help, or even to harm, patients.
Drs. Prasad and Cifu narrate fascinating stories from every corner of medicine to explore why medical reversals occur, how they are harmful, and what can be done to avoid them. They explore the difference between medical innovations that improve care and those that only appear to be promising.
They also outline a comprehensive plan to reform medical education, research funding and protocols, and the process for approving new drugs that will ensure that more of what gets done in doctors’ surgeries and hospitals is truly effective.
Junior doctors in the National Health Service in England have voted overwhelmingly to take strike action if the government does not change its mind about a new contract. Just over 37,000 were balloted, 76% responded and 98% voted to strike. Arbitration may now occur, but the first strikes are scheduled for early December.
Junior doctors are doctors in training posts, on their way to becoming consultants or general practitioners. They remain ‘junior’ for between 4 and 10 years, depending on the specialism and their own circumstances, particularly part-time working. They are allocated to the training posts by “Deaneries”, bodies responsible for overseeing training in the NHS. This allocation of posts can separate couples, and is unpopular with doctors whilst being popular with the NHS. Their basic salaries are in the £23,000 to £40,000 range.
Junior doctors have always worked long hours. In the 1970s an 80 hour week was common, and overtime (after 44 hours) was paid at one of third normal time. Not surprisingly, such exploitation was challenged in a three month industrial dispute in the winter of 1975. The result was a commitment by the NHS to reduce hours, and a somewhat improved pay deal that broke the then Labour government’s pay policy without either profession or government admitting it.
Progress in reducing hours of work was slow. Shorter working weeks meant recruiting more junior doctors but also creating more (expensive) consultant posts for the juniors to graduate into. More junior doctor agitation in the 1990s led to the ‘New Deal’ contract in 2000. This contract was designed to reduce junior doctor hours in a phased way by making overtime expensive for the hospitals employing them. It was punitive towards employers and financial beneficial to some junior doctors – those working frequent long shifts. It was assisted in its aim by the European Commission’s Working Time Directive (introduced in 2004), which specifies hours of work, work breaks and recovery time.
The New Deal contract was built around pay bands. The chart below over-simplifies a complex pay deal, but gives a flavour of the financial rewards (to the doctor) of out-of-hours work. The normal working week is defined as 7am to 7pm, weekdays; out-of-hours work begins at 7pm on weekdays and includes all Saturday and Sunday. A junior doctor working 56 or more hours per week, on average, would double his/her salary. The basic salary increases each year.
Between 40 & 48/week on average –high frequency out of hours work
As for 1A, but medium frequency out-of-hours work
As for 1A, but low frequency out-of-hours work
Between 48 and 56/week on average – high frequency out of hours work
Between 48 and 56/week on average – low frequency out of hours work
Over 56 hours/week on average
New Deal banding is applied to a group of junior doctors in a rota, rather than to individual doctors, for reasons of efficiency. A snapshot of data can be taken across the whole rota, rather than having to count the hours of each doctor for the entire duration of the rota cycle. This also allows any individual variations to be balanced out across the rota. However, this also means that any changes in banding will apply to all doctors on that rota.
The rules about maximum length of duty period and minimum length of time off duty apply one hundred per cent of the time. A single breach of these rules during a monitoring period can make the whole rota non-compliant. In principle, if a single doctor in a Band 2A rota stays at work late or starts early, the result can be that Band 3 payments are made to all the doctors on the rota – every doctor on the same rota will get double pay, even if they have not worked beyond their time limit. The same can occur in any of the Bands.
The current contract is an hours-based rather than a professional contract, focused on working hours, rest time and pay. The system has ensured that doctors can be paid appropriately for the number and pattern of the hours they work. The use of punitive overtime pay to incentivise reduction in working hours has been successful. Since 2007 less than 1 per cent of junior doctors in England have received Band 3 payments. The current average extra payment for junior doctors across England is approximately 45 per cent of basic salary. This reduction in hours has been possible because of the increase in the numbers of junior doctors by an average of 4.5% per year in the first decade of this century. Now that doctors in training are working considerably fewer hours, their average earnings have correspondingly declined compared to previous generations.
Nevertheless NHS Trusts do not like the Banding system. Banding can cost NHS Trusts a lot of money if they end up paying a whole rota extra because one member of it has worked beyond their band limit. It creates adversarial relationships, makes training posts with a higher banding more attractive – which skews the labour market – and does not encourage professional ways of working. Disputes between NHS Trusts and employees about banding can develop during periods when the working hours snapshot is taken, because so much is at stake financially. Annual pay increases are disliked by NHS Trusts because the increment is not dependent on demonstrably increased competence. All this is added to the administrative problem of organising work rotas around complex rules that govern break periods, rest time, the number of long or overnight shifts that are worked in a week, and so on.
Junior doctors do not like the banding system, but for different reasons. Payment for out-of-hours work now constitutes a large part of overall earnings, and so there can be significant variation in income between jobs. This can be a problem for doctors who want to purchase a house, for example, because they cannot predict their future income even in the short term. It may also mean that a junior doctor who moves to a job with higher responsibility but a less intensive working pattern may have lower total take-home pay.
This variability and unpredictability in income adds to financial pressures from increasing levels of student debt and the removal from hospitals of most free junior doctor accommodation. The costs of training and of being a doctor, including mandatory fees for professional registration with the General Medical Council (GMC), membership of a Royal College, examination fees, course fees, certificate of completion of training (CCT) fees and professional indemnity insurance, all rest with the junior doctor. The Doctors & Dentists Review Body (DDRB) has noted that the basic salaries of doctors in training are in the lower quartile for their comparator professional groups. Junior Doctors, whilst well paid at between £30k and £50k per year (including overtime), are beginning to look like members of the ‘precariat’ – especially those with ambitions to work in the of the South East with its over-heated housing market.
The New Deal contract has done its job – of reducing the hours worked by junior doctors – but is now considered obsolete by the Department of Health. Negotiations about a new contract for junior doctors have been underway since 2012. The BMA’s junior doctor negotiators left the negotiations in 2014, in protest at the government’s intransigence, and they have become even angrier since. Industrial action is likely, this December.
The principles – not the substantial terms – of the contract that Secretary of State for Health Jeremy Hunt has proposed include (amongst other things):
The redefinition of normal working hours as 7am to 10pm on weekdays and Saturdays, with nights and Sunday attracting out-of-hours payments;
An 11% increase in basic pay, with pay protection for those who might lose financially;
An end to banding payments;
An end to annual salary increments, with pay linked instead to stage of training;
An upper limit to the numbers of hours worked, and to long shifts.
The response of the BMA junior doctor leadership to these principles has been negative. Redefining ‘normal’ hours to include periods currently reimbursed as overtime will reduce income, although the 11% increase in basic pay will probably offset this for many. The end to banding is seen as a licence for NHS Trusts to exploit junior doctors and make them work more, not less, hours. Abolition of the salary increment is seen as an insult added to the injury of less overtime payment. Limiting hours of work further could lead to a further erosion of overtime pay, whilst shift length and other rules about breaks and rest periods are already in the contract or the Working Time Directive.
Hunt has threatened to impose a new contract based on the principles in August 2016, unless negotiations re-start. This has made the junior doctor ‘precariat’ take to the streets, threaten migration and predict an exodus into better-paid jobs outside the NHS. They see his proposals as a deliberate attempt to worsen of their financial uncertainty. The BMA is supporting its militant juniors, as are many (but not all) hospital consultants. The employers in the NHS Trusts favour the proposed principles, which would simplify out-of-hours payments and reduce their administrative burden, and think the juniors are making a mountain out of a molehill.
It is difficult to know whether Secretary of State Hunt is deliberately promoting a fight, or has blundered into a conflict because he does not understand the undercurrents in the medical profession. He seems unprepared for a dispute. The economic modelling to show who would gain and who would lose from the new contract has not been completed, right up to the strike ballot.
A little history may help clarify this confusion. In 2007 the Blair government tried to introduce an electronic system for matching junior doctor applicants to training programme posts, the Medical Training Application Service (MTAS). The electronic system fell over almost immediately, and caused so much distress to junior doctors that they organised street demos and issued threats of emigration. The government retreated to fix the failed system, but the debacle revealed that 28,000 trainees had applied for 22,000 jobs. The prospect of substantial medical unemployment appeared for the first time in the NHS.
Then in 2012 the Coalition introduced a reform of NHS pensions, ending the final salary pensions that previously made NHS employment such an attraction for doctors. The BMA led a campaign of protests that rapidly petered out, leaving it looking both ineffective and overly privileged. One BMA Council member, Dr Kailash Chand, described the protest as the “wrong fight at the wrong time with the wrong tactics”. In the same year the Coalition introduced the controversial and much challenged Health and Social Care Act that extended market mechanisms into the NHS, in order to reduce system stability and promote competition between NHS and private providers. We can add to this list of conflicts the government’s pressure to implement “7 day working”, and the stresses and strains produced by the short-fall in the health service budget.
Within a few years governments have demonstrated to new entrants to medicine that they face possible unemployment, if successful will work hard in increasingly competitive and potentially unstable environments. At the end of their career they will receive a smaller (although still substantial) pension than their predecessors. The security and stability that the NHS used to offer to its medical staff, even when it was exploiting them, is being eroded. Can we be surprised at the rage of the junior doctors and their apparent determination to strike? Whether they are right about the new contract being a danger to their salaries is almost beside the point.
Much rides on this wave of anger. If the BMA fails to gain concessions from the Secretary of State, it will be damaged. Losing the argument about pensions and being over-ruled in the debates about the Health & Social Care Act have dented its image as the most powerful trades union in the country. Some in the NHS will be secretly pleased if the BMA takes a beating, because some doctors are seen as obstacles to change within the NHS. Angry juniors may decide to organise separately from the BMA, as they did in the run up to the 1975 dispute. If on the other hand the BMA does force Hunt to back down, his job must surely be under threat, especially if public perception continues to favour the junior doctors. The task he was given by the Prime Minister was to keep the NHS out of the headlines. We shall see in December whether this clash is once again the “wrong fight at the wrong time with the wrong tactics”, or a climb-down for the government.
Steve Iliffe took part in the 1975 junior doctors’ industrial action in 1975 as a House Officer at Leicester Royal Infirmary, and was co-author of the history of the dispute, “Pickets in White”, published by the Medical Practitioners Union in 1977.
Jane Bernal, Jill Manthorpe and Linda Patterson commented on drafts of this account, but are not responsible for its contents.
Canadian medical anthropologist Dr. Leigh Hayden and UK-based service designer Kat Matfield describe how techniques from behavioural psychology can help practitioners work more effectively with patients with complex needs.
Patients with complex needs have a confluence of physical and mental health issues that are often compounded with psychosocial challenges. They range from “high users” of health care to the “silently sick”, but overall account for a large proportion of health spending with relatively poor outcomes and experience of care. To improve engagement and experience of this patient population, the health care industry would benefit from new approaches to designing services currently organised around single diseases or organ systems. This paper focuses design exercises using concepts from behavioural psychology to engage patients with complex needs.
Women’s College Hospital is a health care organization focused on providing high quality outpatient care for patients with complex needs. Adaptive Lab is a digital products and services innovation agency that draws on the best practices of the technology sector which successfully embraces user-centricity in its design. The two organizations joined forces to tackle one of the most ‘wicked’ problems in health care today.
The three design methods we describe in this paper use concepts from behavioural psychology, which can be applied to health care to engage patients with complex needs to:
1. Build rewards into a service by prompting new ideas on how to incentivise health behaviours
2. Estimate cognitive load to identify moments of low “cognitive load” which could impede successful engagement of patients with a health service
3. Identify low and high points experienced, and brainstorm ways of minimising memory of lows and maximising memory of highs.
Health care’s challenges in responding to complex needs
Across the globe, but most acutely in developed countries, we are seeing a growth of people with multiple chronic (or long-term) conditions, often compounded with psychosocial challenges. This population is commonly referred to as patients with complex needs.
The growing prevalence of patients with complex needs poses new challenges to medicine and health care which are currently organised by disease or organ systems. Challenges for patients with complex needs include the following:
Care at various clinics that is often disconnected and sometimes competing.
Motivation, and social, financial, and cognitive resources required to engage in self care and follow medical instructions.
Burden imposed by care that requires engagement in several activities to achieve optimal health, which manifests itself as poor patient experience in patients with multiple chronic conditions reporting lower satisfaction and quality of care.
Deprived social conditions (e.g., poverty, housing issues, under-employment) that increase chronic disease risk, are barriers and disruptions to medical care and adequate self care, and threaten available resources for health care and health promotion.
The expense and threat to economic livelihoods imposed by a chronic condition.
These challenges can also result in poor patient compliance, worsening disease outcomes, increased morbidity and added cost. Overall, health care would benefit from re-design to provide a more collaborative, streamlined and engaging approach for people with complex needs.
Greater focus on “high users”
“High users” are defined as the 1-5% of a population that uses the greatest amount of services, whether measured by utilisation rates or cost. Those at risk include patients with HIV/AIDS, a serious and persistent mental health condition, or multiple chronic conditions. Contributing social issues include lack of home ownership, low incomes, and food insecurity.
Developed countries are focusing on containing the utilisation and/or costs of high users. In Ontario, Canada, the top 5% account for 66% of health care spending. In New York state, the top 5% account for 48% of health care spending.
The hard to reach “silently sick”
At the other end of the spectrum are the “silently sick”, who choose not to, or are unable to seek care from the mainstream health system, despite poor health. This disenfranchised group live with morbidity that could be treated.
Reasons for this potential disenfranchisement include:
Mistrust of the system for historical or cultural reasons
Health-seeking as an activity is not valued
Difficulty in accommodating health appointments and self-management requirements
Lack of awareness of available health and social services.
When the “silently sick” do seek care, they are often confronted with previously identified deterrents, which then perpetuate tension, and may cause confusion and inappropriate care.
User-centricity in technology
Behavioural psychology has had a marked influence on how the technology sector approaches product and service design. Fogg’s 2009 influential behavioural design theory has three key elements: motivation, ability and trigger. These must intersect simultaneously in order for a behaviour to occur. A user must have both the ability and motivation to engage in that behaviour which must be prompted or triggered until it becomes a habit. The more difficult the behaviour (ability), the higher the motivation required. Motivation is difficult to sustain, so Fogg proposes “motivation waves” to capitalise on periods where users are naturally more highly motivated. Ability is typically easier to target than motivation.
Design theory and methods often use these approaches to produce a desired behaviour, which may be as equally influential on consumer behaviour, (e.g., downloading an app), as on facilitating a health-related behaviour, (e.g., improving sleep patterns). To complement such approaches, anthropological insights are needed to appreciate the cultural and socio-economic context in which decisions are made, and the power and class matrices in which certain behaviours, like eating vegetables, are preferred over others, like drinking alcohol.
Our objective was to develop tailored design techniques to specifically engage patients with complex needs by using research-based insights into the struggles of people with complex needs and theoretical direction from behavioural psychology.
We tested three newly-developed design methodologies in order to tailor them to people with complex needs, in whom illness may result in lower physical and cognitive endurance, lower concentration, and lower tolerance for services that do not produce an immediate desired result.
For each exercise, we defined the flow, desired outcomes, participant criteria (number and make-up), and materials required. Participants recruited included designers and web developers at Adaptive Lab. Exercise review and feedback through retrospectives enabled us to identify gaps, possible modifications, utility, appropriate timing, and guidance on re-design. This iterative design approach enabled us to implement modifications to each exercise.
Design Method 1 – Reward Card Game
This exercise was designed to build “rewards” into a service. It is a card game intended to prompt new ideas about how to incentivise health behaviours.
Health care is a participatory practice, often involving new practices (e.g., appointment attendance, fasting for blood tests, dietary changes), which are inherently difficult to integrate into a routine. The promise of uncertain future benefit competes with certain present enjoyment. In health care, the information deficit model is often used; if patients understand what they were asked to, they will conduct themselves accordingly. Empirical evidence suggests this model often fails. Providers, without other tools, default to guilt and shaming to encourage patients to behave according to the medical model. Behavioural psychology offers approaches which could be built into the service, increasing the effectiveness of the patient-provider partnership, and avoiding negative tension and resentment in patients.
Nir Eyal’s influential book “Hooked: how to build habit-forming products” outlines his techniques to help designers build products that users habituate into their daily lives. These so-called “habit-forming products” have inbuilt cognitive rewards which promote use and habituation. His concepts can be applied to service design by exploring how different “types” of rewards can be used to create more satisfying and habit-forming products and services.
Eyal groups rewards into three categories demonstrated in Table I.
Table 1: Eyal’s Cognitive Rewards 
Types of reward
Rewards of the Tribe
Social acceptance and belonging
Valued social rewards by social beings:
Rewards of the Hunt
Need to acquire resources to aid survival, context dependent
Things of value (e.g., food)
Rewards of Self
Personal gratification, and sense of pride and purpose
Develop a number of possible methods to reward desired user behaviour to enable a product or service to become “stickier”.
The “Virtual Ward” programme for patients with complex needs provides close monitoring after hospital discharge, but engages patients in a number of self care activities which are often encouraged using guilt and not rewarded using good design.
The exercise was conducted with one moderator and three participants.
Preparing for the exercise took one person one hour. Two sets (colours) of cards were developed: 1) User behaviours that the product or service require to work optimally; one behaviour per card, 2) All of the reward categories (listed in Table 1); one reward per card.
The exercise took 30 minutes from explanation (including the behavioural psychology concepts) to completion. Budget for 45 minutes for a group unfamiliar with design exercises and concepts from behavioural psychology. Participants enjoyed the exercise, however the concepts, although interesting, required a large assimilation of new knowledge in a short timeframe. Creation of a figure to demonstrate the types of rewards with a brief description (or examples) of each will facilitate improved understanding at the onset of the game.
To maintain the flow of the exercise, if a participant is not able to think of a reward of the type drawn, the turn should move onto the next participant after 10-15 seconds. This occurrence is a reality as some behaviour-reward combinations may not make sense.
This exercise, although helpful for brainstorming ideas for rewarding programme-specific behaviours, can also be used to initiate a design exercise which aims to form habits. The exercise can be modified for larger groups by splitting them in two groups, each doing the same exercise. This increases competitive engagement and produces more ideas. Reconvening after the exercise allows for comparison of answers and voting to select the best.
Overall, this exercise has promise. Seeking and receiving health care typically has multiple disincentives and barriers, such as long wait times, long travel distances, or recommended activities that are confusing and/or difficult to incorporate into daily routines. Incorporating rewards into a health service, to keep patients engaged, give them additional incentive and motivation to withstand inevitable difficulties, is novel and has promise for patient engagement, patient activation, and patient-provider relationships.
Design Method 2 – Assessing Cognitive Load
This exercise involves estimating cognitive load to find patients’ most receptive moments. It has been designed to identify moments of low “cognitive load”, to help choose the appropriate moment to onboard a patient into a new programme or service.
Cognitive load refers to the amount of information being processed by the working memory at any given time. It is a sum of the intrinsic and extraneous loads. Intrinsic load is inherent to the contents of the material being learned; more difficult or complex concepts have a higher intrinsic cognitive load. Extraneous cognitive load is anything that consumes working memory or cognitive processing which is not concerned with the material at hand. This includes unrelated information or material, or other cognitive inputs such as noise or other distractions, which compete for attention and working memory.
Cognitive load is influenced by:
Novelty – whether the learner has been exposed to it before; if they have, it consumes less working memory
Other distractions, e.g., multi-tasking
Learner’s current “mode” – this could be “habit” mode (e.g., early morning when getting ready for the day) or “learning” mode (e.g., evening when more relaxed)
Complexity of the material presented, which can be reduced through simplification and avoidance of jargon and new vocabulary
Learner’s emotional state – if they are in an excited state, they have less capacity for decision-making.
Seeking and receiving health care and self care requires patients to learn and integrate these activities, and the rationale for conducting them, into their lives. When introduced at a period of high cognitive load, integration of new ideas and activities is more challenging, possibly reducing ability to engage in the care or service. This creates a poor patient experience which could potentially be avoided or reduced.
Determine the best “moment” for engagement and consider ways of reducing cognitive load.
The “Virtual Ward” programme for engagement was used
Three engagement timeframes were used – at the hospital before discharge; 48 hours after discharge at the patient’s home; and 1 week after discharge at the patient’s home.
The exercise was conducted with four people (three designers and one programmer). Two people moderated the exercise.
Preparing for the exercise took two people one hour. Cognitive load mapping “cards” (Figure 1) were developed for participants to score the cognitive load dimension for each scenario. Once complete, the cognitive load can be assessed at a glance to quickly identify moments of low cognitive load. Questions cover the following concepts that influence cognitive load: background, environment, complexity, impact and novelty. Pointers to note are as follows:
The first cognitive load question should focus on anxiety/excitement.
The description of the concepts should enable clearer questions.
A familiar topic/situation should be selected to improve the utility of the exercise.
The cognitive load questions should be grouped by topic (context, current environment, decision, emotion).
Figure 1: Cognitive Load Mapping Card
Are they in an excited state?
What time of day is it?
Has their day been busy?
not at all
Is their current environment distracting?
not at all
Are they currently multi-tasking?
not at all
Do they have to absorb lots of information?
Do they have to grasp any new concepts, or words?
Have they done something like this before?
done this before
done something similar
never done anything like this
Are there a lot of options of what to do?
Is it hard to choose between the options?
not at all
Will the impact of the choice/task be serious and/or long lasting?
not at all
The group completed the exercise for a problem (engagement with the Virtual Ward programme) with which they were unfamiliar. As such, they struggled with the exercise and required explanation from the moderator regarding the user journey and circumstances.
In a second iteration of this exercise participants focused on a relevant problem, the engagement of patients with a project they were working on. Using the project’s user journey map, the cognitive load at three distinct moments was observed, to give some empathy into the state of the user during the various steps of the journey. The exercise took 30 minutes. About half way through the exercise, the group led itself.
Assessment of the usability and specific utility of this exercise highlighted the following insights:
In health care, programme engagement, patient education and other communication-rich activities are typically completed at times convenient to the care provider or system. This exercise is valuable because it forces programme designers to consider how receptive patients may be and when best to undertake these activities. This level of empathy is uncommon in health care design and could be especially helpful for patients with complex needs.
It is ideal for the participants to be familiar with the problem at hand, ideally patients/users themselves.
The exercise could be combined with a user journey map, to explore cognitive load at each step of the user’s journey.
It is beneficial conducting the design method exercise early in a project design process, but not right at the beginning. This is allows for insight provided by this exercise to be more easily incorporated into a service design.
To focus discussion after completion of the exercise, the following question should be posed to participants: are there ways of removing cognitive load (e.g., by using default options), spreading the load out or shifting it, or simply removing elements to simplify the user experience?
This exercise will capture hypotheses about users – specifically about their environment and context. The group may need to make a number of assumptions about the user’s context and environment. These assumptions should be tested to determine their validity. Alternatively, this exercise could be done by researchers who have developed a deep understanding of the patient experience.
Design Method 3 – Designing for the remembering self
Daniel Kahneman’s book “Thinking Fast and Slow” has heavily influenced behavioural economics and popular understandings of human behaviour. He describes the “two selves” – the experiencing self and the remembering self.
He argues that happiness is a function of our experiencing self, that assesses our current life, and our remembering self, that assesses our memories of prior experiences. His research suggests that our remembering self has a greater influence on our happiness. We live according to the stories we create of events (which may not fully reflect the experience we had at the time). Moreover, the endings of our stories are especially important and frame the entire event.
Social science also recognises the importance of personal narratives – the constructions of memory that provide meaning and coherence to our experiences and sense of self. The differences between actual events and our memory of them and the role of narrative in linking discrete data to enhance memory and comprehension are of interest.
The importance of memory can be applied to the patient experience. For patients, health care can have unavoidable negative experiences, e.g., pain, discomfort, embarrassment, and/or confusion. In addition, health care can have avoidable negative experiences, such as inefficiency, ineffectiveness, poor treatment, lack of treatment.
To improve patient experience (one of the triple aims of health care, identified by the Institute for Healthcare Improvement), work can be done to remove the avoidable potentially negative experiences. However, even if this work succeeds, not all negative experiences are avoidable. In these cases, an attempt can be made to influence how patients remember their experience, and thus improve their overall experience and wellbeing. In addition, by improving patients’ positive memories of the experience of a health service, we can also increase the likelihood that they will continue to use the service and be engaged in it.
Identify the high and low points of an experience, and brainstorm how to minimise the memory of the lows, and maximise the memory of the highs.
This exercise could be conducted during the pilot phase of a new programme, or during the design phase, by exploring patient experiences of similar programmes. It could also be used to improve existing programmes.
The exercise can be conducted with one moderator and two to four participants.
Budget one person 30 minutes to prepare for the exercise. They must develop two sets of cards: 1) for reducing memory; red in colour, 2) for increasing memory; green in colour. Each set consists of three of cards stating – “repetition”, “attention”, “emotional impact”.
The exercise took 45 minutes including explanation, the exercise, and a retrospective. Participants conducted the exercise using both service and product experiences. Examples included: signing up for a web service and ordering something for home delivery. Participants struggled with remembering a “poor” or “exceptional” experience, and subsequently many of the details around that experience.
The exercise is best done for real problems encountered, because we found that we needed to probe participants to be as granular and specific as possible about what went well and poorly. It worked better for service experiences than product experiences, as these had multiple different steps.
This method is best used for experience design, and paired with a user journey map to map out the experience then chart the good or bad qualities of each step. From this map, it is possible to focus in on particularly good or bad experiences, or clusters. This initial map is best conducted with real users who can describe their experience in detail, although it may not be appropriate to involve these users in discussing how the memory of the experience can be improved.
It is optimal if a bad experience can be avoided or designed out. Merely decreasing its memorability, when you can eliminate it, is suboptimal. In health care, there is a need to deeply interrogate whether bad patient experiences can be avoided, and avoid presuming that these experiences are inevitable. However, some of the discomforts of “poking and prodding” in health care are unavoidable, and dampening their impact and memory may be both compassionate and beneficial.
Our work has demonstrated that behavioural psychology concepts can be used to develop exercises to explore health care design problems. Although the exercises above were designed with health care in mind, it is possible that they may be applied to other design problems. It would be worthwhile to test their broader applicability.
Our work also demonstrates that participants can successfully learn how to apply behavioural psychology concepts to assess situations and provide design insight. An important caveat is that the exercises were not tested with “patients with complex needs”, but rather, with design lab employees who are skilled at learning and applying new concepts. Using internal staff and other industry people to test exercises first to identify major problems is helpful and cost effective. The next step is to test the tested and revised exercises with real users focusing on their health care design problems or possible experiences.
The success of these exercises in the design process is a product of several factors, including identifying the:
appropriate design problem
relevant user population
most receptive moment for implementation.
Further exploration and testing of the exercises’ situational utility in relevant populations will promote further user-centric improvements.
We have identified, trialled and adapted user-centric design methods for health care in order to inform design of technology solutions, to enable patients to better engage with health care services and health improving behaviours. We have taken these approaches from the tech industry one step further and applied novel design methods to better address the health service needs of patients with complex needs. Using concepts from behavioural psychology, we developed these design methods to specifically engage patients with complex needs who are arguably underserved in the current system, and to improve user experience (and potentially) outcomes. Patients with complex needs often live very different lives compared to those who design and provide health care, and their care is in itself very difficult to do well, so soliciting their input could be a valuable way to improve their experiences and outcomes. Our approaches, informed by behavioural psychology, are intended to solicit their views and explore their lives.
Our work represents a novel approach to engaging complex and disenfranchised users. The exercises used in co-design with this population are typical exercises (consumer mapping, developing user profiles, card sorting), or modifications of these common exercises. To our knowledge, no others have developed exercises based on behavioural psychology, which target patients with complex needs. Theory-driven approaches to design exercise development are uncommon and have real potential.
Further application in health care to address real problems with real patients is needed. However, this research has enabled a crucial first step. The exercises above are both novel, adding to the arsenal of design exercises commonly used, and specific to use in instances in which low acceptability and low satisfaction are probable, instances that are not uncommon to health care.
The next phase is to implement the design methodologies in the community by partnering with service organizations (such as health care organizations and patient groups). This can also draw on previous experience with re-designing services and systems for other complex and disenfranchised populations, such as vulnerable families, and homeless people . Designing services with end-users may identify wider system barriers. While designers are process-driven, providers are solution-driven and have intimate knowledge of patients’ struggles and needs, and can help overcome these barriers.
Behavioural psychology concepts, although not originally designed for application in services for patients with complex needs, can be used to facilitate increased acceptance of health services by focusing on the “how” of service design, and less on the “what” of service design.
Dr. Leigh Hayden is a medical anthropologist working at Women’s College Hospital, in Toronto, Canada and Kat Matfield is a Service designer working at Adaptive Lab, London, UK.
1. Schaink AK, Kuluski K, Lyons RE, et al. A scoping review and thematic classification of patient complexity: offering a unifying framework. Journal of Comorbidity. 2012; 2(1):1-9.
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3. Eton DT, Ridgeway JL, Egginton JS, et al. Finalizing a measurement framework for the burden of treatment in complex patients with chronic conditions. Patient Relat Outcome Meas. 2015 Mar 27; 6: 117-26.
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6. Fitzpatrick T, Rosella LC, Calzavara A, et al. Looking Beyond Income and Education: Socioeconomic Status Gradients Among Future High-Cost Users of Health Care. Am J Prev Med. 2015 Aug; 29(2):161-71.
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8. Veillard J, Denny K. Transformation through Clinical and Social Integration: Meeting the Needs of High Users in Healthcare. Healthcare Papers. 2015 Apr;14(2):4-7.
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· 2.5 year scientific evaluation of European integrated care programs and 2,500 surveys provide unparalleled insights on success factors of connected care programs across the European Union
· Advanced Care Coordination and Telehealth Deployment (ACT) program addresses EU’s aging population and burden of managing chronic conditions
Royal Philips (NYSE: PHG, AEX: PHIA) and its ACT-program consortium partners today announced the debut of a ‘cookbook’ outlining key enablers necessary to scale connected care and telehealth programs. The cookbook is the result from a two-and-a-half year scientific evaluation of data from different connected health programs in five European regions. It provides new insights that apply across the EU on why certain telehealth programs are more successful than others.
Connected care is seen by many governments as essential to enable more efficient, patient-centric and continuous care for the aging EU population; however, although many local connected care pilot programs are successful, they fail to scale and their potential impact is not fully leveraged.
The consortium researched data from patients with COPD, diabetes and heart failure in programs in the Basque Country (Spain), Catalonia (Spain), Scotland (UK), North of the Netherlands, and Lombardy (Italy) and conducted 2,500 surveys and group interviews with participating patients and care providers.
The consortium found that the scalability of care coordination and telehealth is possible, but requires significant organizational change to successfully execute the process. It also unveiled critical areas in which progress is required in order to enable the transformation to more sustainable healthcare systems.
The Cookbook advises that patients are assigned a single point of contact when enrolled in care coordination programs with several institutions and care providers to prevent them from feeling lost and diverging advices. Staff engagement is critical as in programs where staff understanding and engagement levels were high patient adherence was better compared to programs with lower engagement scores. Preventative care programs outperform reactive healthcare delivery. Improved standardization and interoperability within the European Union would enable benchmarking and leveraging successful programs beyond local pilots.
“A significant portion of our population is 65 years or older, and managing chronic conditions continues to put stress on our healthcare systems,” said Andrus Ansip, Vice President, Digital Single Market, European Commission. “Smarter use of innovation is crucial in order to enable active aging and healthy living. The ACT-program illustrates care coordination and telehealth can be very successful instruments to address care needs. The cookbook will inspire the necessary debate on system transformation and will help with the scaling of future connected health programs.”
“Successful coordinated care and telehealth are principally about organizational change,” said Professor Stanton Newman of Health Psychology, School of Health Sciences, City University London, UK. “To achieve the best outcomes for patients, we need to review the way these organizations are structured and make sure everyone is aligned on the objectives and goals of integrating care coordination and telehealth into patient care pathways.”
“Connected care is critical to the future of our healthcare systems,” said Jeroen Tas, Chief Executive Officer, Healthcare Informatics Solutions and Services, Philips. “The ACT research shows that successful connected care services may start with having the right technology, but it is truly about the holistic approach of technology, processes and people to make an effective transformation.”
The cookbook is available for download and more information can be found on the ACT Program’s website.
Uniting leading European healthcare experts from a number of domains, the ACT program is part of the European Innovation Partnership on Active and Healthy Ageing (EIP-AHA). The EIP-AHA is an initiative from the European Commission under its Innovation Union strategy, and aims to increase the average healthy lifespan by two years by 2020.
Brits can expect to start suffering headaches and migraines at the age of 24, back problems at 33 – and get their first grey hair at 39, a study has found.
The study of 2,000 adults revealed the age we can expect to get struck with certain ailments, with dodgy ankles creeping in at the age of 32 and weak knees a problem by 37.
It also emerged most women get hot sweats by the time they’re reach 50, while the average Brit will be moaning of arthritis and joint pain by 40.
And despite keeping fit when they were young, one in five said they now suffer from problems due to historic sporting injuries.
The poll found the main concerns for Brits were the health of their heart, memory problems and high stress levels.
A spokesman for vitamin brand Healthspan, which has launched a personalised supplement service, Uniquely You, said: “It’s inevitable that as we age we will get more health complaints, as youngsters you are more resilient and can shake things off far quicker.
“The research shows by the time we reach our thirties, everyday ailments like joint pain, headaches and digestive problems are more common place.
“Even those who have kept up a fitness regime throughout their twenties are often set back by problematic ankles, knees and backs.”
The poll also found more than half said once they hit 30 the ailments, started racking up, with two thirds saying they can feel their health deteriorating as they get older.
Contrary to this – a quarter said they feel better than they have felt in a long time with four in ten said on the whole they are ageing better than their parents did, with 60 per cent claiming they take better responsibility for their health the older they get.
Four in ten adults said they felt at their fittest while in their twenties, although a quarter said it was in their thirties they felt at their peak health wise.
More than half said things like cold weather affected their health much more as they got older with 15 per cent claiming broken bones from earlier life causing them gyp in the cold weather.
Three in ten also said certain lifestyle choices they made when they were younger were rearing their head as the years go by.
The biggest contributor to current ailments were found to be a poor diet, lack of exercise, too much booze and lack of sleep.
Smoking and too much sun exposure were also bad habits people listed for poor health now.
One in ten blamed working shifts for ill health and a quarter said a highly stressful job has contributed to some of the ailments they suffer from.
The study also found that the typical Brit gets sick three times a year but doesn’t visit a doctor.
Although nine in ten adults were in agreement that people should take more responsibility for their health as they got older.
Despite the study showing that the typical Brit takes one vitamin a day, 36 per cent are confused over what supplements they should be taking.
In fact, 31 per cent of people claim they have packets and bottles of health supplements that have been sat in the cupboard unused for a year or more.
More than half say they just forget to take them and a quarter say they were going through a health kick when they bought them.
A spokesman for Healthspan, Uniquely You added: “Every week there is differing advice on what we should all be eating, drinking and how much exercise we should be getting, so it’s understandable that knowing what supplements we should all be taking is confusing for people.”
Rob Hobson, Uniquely You Nutritionist said: “It’s important to remember that what applies to someone suffering from joint pain will differ to that of someone with digestive problems and the one-size fits all model no longer works.
“People want to personalise their nutrition and two thirds of those polled said they want supplements that are personal to their own health concerns.
“We tailor the combination of supplements to an individual’s needs, so whatever your health concern, we can find the right combination of supplements for you.
“Everything about health and wellbeing is moving towards personalisation.
“Research has already unveiled links between specific nutrients and disease protection, and this will inevitably evolve over time, especially with the growing interest in areas such as nutrigenomics, where your own genetic make-up could dictate the way you eat.”
Age of ailments
Headaches and migraines – 24
Weak ankles – 32
Back ache – 33
Weak knees – 37
Grey hair – 39
Joint pain/arthritis – 40
Hot sweats – 50
New study of internet-delivered intervention, Space from Depression, demonstrates effectiveness as a treatment option for people with symptoms of depression
10th November 2015 – SilverCloud Health, a global provider of online therapeutic solutions, together with Ireland’s depression charity, Aware, and the School of Psychology, Trinity College Dublin (TCD), today announced the success of a Randomised Controlled Trial (RCT) of Space from Depression, an internet-delivered Cognitive Behavioural Therapy (CBT) programme, which targets symptoms of depression.
Published online in Behaviour Research and Therapy the study, undertaken in Ireland, is the first nationwide RCT showing the efficacy of the Space from Depression programme, delivered by Aware, through its network of specially-trained supporters under the name Life Skills Online.
In the study, at post-treatment more than 50% of the participants were observed to be in either remission and / or recovered from their symptoms, and importantly these gains were maintained at 3-month and at 6-month follow up1. Users accessed the programme directly through Aware for eight weeks with the support of weekly reviews and guidance from their Aware trained supporter.
The study has shown how the programme can be successfully delivered at a population level with positive outcomes. This has implications for how treatment could be delivered more broadly at a UK wide level, particularly in locations where behavioural and mental health services are underdeveloped or under-resourced.
Dr. Derek Richards, Director of Clinical Research & Innovation at SilverCloud Health and Research Fellow at School of Psychology TCD said, “Together with the positive outcomes reported for depression, this study also highlights the possibilities for innovative models of health service delivery. Internet-delivered interventions including Space from Depression are now being delivered in primary care settings as a stepped care intervention. Effective evidence-based programmes can reduce barriers to treatment access such as waiting lists, offering benefit to healthcare providers and reducing costs of delivering quality care.”
· Significant improvement for those who used the programme with statistically significant changes from what is considered the threshold of clinical depression symptoms (>14 on the Beck Depression Inventory), and these positive changes were maintained at 6 months post-treatment.
· Significant reduction in comorbid symptoms of anxiety maintained at 6 months post-treatment.
· An improvement in work and social functioning, from pre- to post-treatment with continued improvement over time.
Dr. Claire Hayes, Clinical Director of Aware said, “The success of this nationwide study highlights the clinical value of internet-delivered interventions and the particular effectiveness of regular support and encouragement such as that provided by Aware’s trained supporters to participants on the programme.”
Although parity of esteem between mental and physical health has been a high profile political issue, difficulties in accessing evidence-based treatments for mental health remain. The worldwide treatment gap in depression has been estimated at 56.3%2 while depression affects nearly 1 in 6 people in the UK.
Space from Depression has been designed to provide therapeutic treatment for individuals experiencing mild to moderate depression and anxiety. It features an 8 module treatment which users access at their convenience and is available 24/7 and that they complete at their own pace. Users also have access to trained online supporters who are available to provide guidance.
Within the UK, Space from Depression can be accessed via many NHS Trusts, healthcare providers and organisations.
A well-designed RCT is considered to be the most scientifically rigorous method of evaluating an intervention’s true effect4. One of the study’s principal investigators Dr. Ladislav Timulak at the School of Psychology, Trinity College Dublin said, “RCTs help to shape healthcare policies, ensuring the highest standards of quality and care for patients.”
To read more about this study please go to Science Direct.
On November 9th the CQC (Care Quality Commission) warned that 40 per cent of care homes for older people are below standard. Andrea Sutcliffe, the CQC’s chief inspector for adult social care, said that a third of social care facilities required improvement, with as many as seven per cent providing “inadequate” services.
Stephen Burke, Director of ‘Good Care Guide’, the TripAdvisor style website for the care industry, argues that the government must react to the care crisis, and suggests the following steps:
1) The government should commission an independent review to establish ‘fair care funding’ and ensure that local authorities pay at least the minimum rate required for both care home places and home care services. Alongside this review the government must fund councils properly to ensure that care providers are paid at or above the agreed minimum rate.
2) Care providers for their part must also commit to greater transparency, for example, of the wages they pay, staffing levels, profit margins and shareholder dividends. As private companies funded by public money, they should be accountable not just for the quality of care they provide but also for the way they run their businesses.
3) The investment in integration of care and health must be stepped up several gears, with one integrated budget at local level. Local authorities and CCGs(Clinical Commissioning Groups) must be required to demonstrate how effectively they are using this funding, for example to keep people out of hospital and residential care.
4) Following what is in essence the scrapping of the cap on care costs, the government should look at better ways to protect families from catastrophic care bills. One such measure would be to raise the threshold for paying for care from £23,250 to £250,000 (the average cost of a home in the UK). It is estimated that such a move would cost the same as the postponed cap and it would be a lot easier to administer.
He added: “Providing quality residential care is becoming unsustainable, especially if a care home relies on local authority income. That challenge will become even tougher next year with the much heralded increase in the national minimum wage. All the above should be seen as steps on the way to the long term sustainability of care funding. That will also require a new way of paying for care that is fair and effective.”
ORAL CANCER is now the tenth most common cancer in men according to new figures* released by Cancer Research UK today (Tuesday).
This latest data shows around 7,300 people were diagnosed with oral cancer in the UK in 2012** and twice as many men than women diagnosed with the disease –around 4,900 males and 2,400 females.
It is the fifteenth most common cancer in women.
Over the last decade, cases of oral cancer have risen from around 4,500 back in 2002. The incidence rate of the disease has increased by a third over ten years, rising from 9 per 100,000 people in 2002 to 12 per 100,000 in 2012.
Because of this sharp rise in oral cancer cases, Cancer Research UK has partnered with the British Dental Association and the British Dental Health Foundation to raise awareness of oral cancer during Mouth Cancer Action Month. They are launching a new oral cancer toolkit*** for dental professionals and GPs to help try and spot the disease earlier.
The free toolkit for health professional features images of signs and symptoms and outlines how GPs and dentists should refer patients for further tests. Health professionals also accrue credit for their continued professional development by completing the toolkit.
There are around 2,300 people who die from oral cancer in the UK every year, around 1,500 men and around 770 women.
Oral cancers include cancer of the lips, tongue, mouth (gums and palate), tonsils and the middle part of the throat (oropharynx).
Around nine out of 10 oral cancer cases in the UK are linked to major lifestyle and other risk factors. For example, an estimated 65 per cent of oral cancers in the UK are linked to tobacco smoking. The human papilloma virus (HPV), drinking alcohol and having a diet low in fruit and vegetables have also been linked to oral cancer.
Higher smoking rates in men are largely responsible for the greater number of cases in men and an estimated 70 per cent of oral and pharyngeal cancers in males in the UK are linked to tobacco smoking.
Dr Richard Roope, Cancer Research UK’s lead GP, said: “It’s a real concern that oral cancer cases continue to climb and has now broken into the top ten most common cancers in men, especially as the majority of cases are preventable. The combination of tobacco, drinking alcohol and HPV provides a toxic cocktail that has led to this rising tide of cancers, so it’s vital that people are aware of how to reduce their risk. If oral cancer is found at a late stage treatment options are more likely to be limited with long-lasting side effects and the chances of survival are poor. It’s because of this that we’re working to raise awareness of the risk factors of the disease as well as helping doctors and GPs spot the signs and symptoms and have the knowledge they need to act.”
Professor Richard Shaw, a head and neck surgeon based at the University of Liverpool involved in developing the GP and dentist toolkit, said: “We know that the vast majority of oral cancer cases could be prevented, so it’s important that people know how to reduce the risk of the disease through lifestyle factors. Alongside this, it’s vital that GPs and dentists can spot signs and symptoms of the disease to help catch it early and that they feel confident in knowing the next steps they should take in referring patients for further tests. Having seen the devastating impact that oral cancers can have, I hope this toolkit will help more cancers being detected at an earlier stage, when treatment is more likely to be successful. I can only see a limited number of patients every week, but this toolkit means more people will have the knowledge to spot the disease early.”
Professor Damien Walmsley, chief scientific advisor to the British Dental Association, said: “If oral cancer is spotted early survival rates can reach 90 per cent. Delay is costing lives, so it’s vital that front line health professionals have the tools and the information to reduce the risk of the disease and get patients diagnosed as quickly as possible. We are proud to team up with Cancer Research UK, and we urge all those who work in the oral health field to make use of this toolkit.”
Access the dental professionals toolkit here or the GPs toolkit here.
As a recent user of the NHS at one step removed, the inadequacy of current funding is all too apparent. Now the NHS Confederation has done the sums and worked out that by 2020 the Service will require £30 billions more than at present because of changes in medical technology, the growing population base, and the ageing of that population.
The attached info-graphic from the NHS confederation sets out visually the strategic impact this NHS funding chasm could have and indicates the broad areas where health and care services may need to change to meet this crisis.
The Confederation suggests that in order the fill this funding gap a transformation of services across both the NHS and the care sector is required which needs to be planned now to stop this becoming true by 2020.
Annual admission rates 2% lower than expected in areas with more restrictive policies.
Tighter local alcohol licensing curbs are linked to fewer drink-related hospital admissions in these areas, reveals research published online in the Journal of Epidemiology & Community Health.
In areas with the most restrictive licensing policies, annual drink-related admissions were 2% lower than would have been expected if no active policies had been in place, the findings show.
Alcohol misuse costs the NHS in England alone an estimated £3.5 billion every year. But that excludes the additional annual costs of drink-fuelled crime of £11 billion, and a further £7.3 billion in lost productivity.
The proportion of regular drinkers has fallen since 2005. But around a third of women and more than four out of 10 men exceed recommended weekly alcohol limits, while regular drinking is become more common among middle aged and older adults.
The researchers assessed the alcohol licensing policies and responses to alcohol licensing applications made to 326 local authorities (councils) between 2007-8 and 2011-12.
Council licensing policies allow for the creation of designated cumulative impact zones, or CIZ for short. These aim to regulate the number of new alcohol outlets in areas where the addition of more would undermine crime prevention and public safety, create a public nuisance or potentially expose children to harm.
The research team generated a ‘cumulative licensing intensity score’ for each council, based on whether they deployed CIZ and/or whether they refused to grant licenses for new premises. The score was divided into four categories: no activity; low; medium; and high.
In 2007-8, 118 out of 319 (37%) local councils operated some form of active alcohol licensing policy, one in five of which also included CIZ for new premises.
The cumulative intensity licensing score was classified as medium or high in around a third (35%) of councils; 43% were classified as no activity; while 21% were classified as low.
By 2014, a further 63 councils had adopted active alcohol licensing policies.
The researchers also looked at the number of drink-related hospital admissions, standardised for age, in each of the local areas from 2009 up to the first quarter of 2015.
After taking account of influential factors, such as deprivation and drink-fuelled crime, the analysis showed that the intensity of alcohol licensing policies was associated with a reduction in drink-related hospital admissions between 2009 and 2015.
The largest effects were seen in those local authority areas operating the most comprehensive policies.
Drink-related hospital admissions fell by an average of 0.6% every year in those local authorities with a medium score—twice as large as the fall in the average admission rate between 2009 and 2015 in those local authorities without an active alcohol policy.
In the local authorities classified as high, drink-related hospital admissions fell by 2% every year, or around 8 fewer drink-related admissions per 100,000 of the population in 2015, compared with what would have been expected in the absence of any active policy.
The researchers emphasise that this is an observational study, so no firm conclusions can be drawn about cause and effect. And they point out that the findings could also be the result of other additional alcohol policies, such as late night levies, or alcohol screening, which they did not investigate.
But they conclude: “These analyses contribute to the available evidence on the effectiveness of population level alcohol licensing policies specifically for England, and are the first to demonstrate that the intensity with which selected alcohol licensing policies are implemented and scrutinised is related to measurable reductions in alcohol attributable hospital admissions.”