Bravo GDS on the new Service Standard that ensures and assures quality, might we talk about health?

With the latest iteration of the GDS service standard now covering full, end-to-end (not just digital) services, I’ve been thinking about how it might work when applied in a healthcare setting, and if it can be combined with other healthcare assurance models.

What happened this week?

Poster of the updated Service Standard

This week the Government Digital Service published a revised Service Standard and you can read Stephen’s ‘behind the scene’ blog at ‘Welcome to the updated Service Standard’. It’s great work, drawing a focus to ‘the whole service’, and ‘joining things up’.

The draft has been in formation for a while, and there have been a number of workshops (which me and the team have been involved in) discussing the implementation of this. So bravo GDS for making this live (and colleagues across Gov, Local Gov and Health for their input in the workshops I attended).

What is a service standard?

If you’re not part of Gov or identify with the Digital, Data and Technology Profession view of the world you might not be familiar with this work, and the role of a Service Standard. For example in health you might work in a local trust, or are proving primary services as a GP, or are a commercial health provider building services.

You can read about ‘Service assessments and applying the Service Standard’ on GOV.UK — it’s a good read, and good practice if you’re involved in services with a digital aspect.

From my point of view, a Service Standard is the way in which you know the service you are building or delivering is fit for purpose — that it centres on user needs, has put accessibility matters at the heart of what you do, that you’ve assembled a team that optimises your chances of success, and that you’ve thought about the technical aspects in the right way. It can be used informally by teams to ‘model good practice’ and it can be used formally to control spend, and to assure quality for senior sponsors (including in Gov, Cabinet Office review).

It’s a good thing, and it’s about both the product you’re building, and the way in which you’re building it.

If GDS have ‘smashed it out of the ground’, why are you blogging again?

I’m blogging for two reasons, the first is to draw attention to this new landmark for GDS (and in general their excellent work), and the second is to stimulate a discussion about some unique aspects of health.

Based on more than 200 hours of user research with people working within health, many of who have had experience of earlier iterations of the GDS Service Standard or worked in Gov departments, we think there may be some things to have more discussions about.

In February at our public show and tell we talked about our discovery work on Service Standards from two perspectives — the first as a structure that helps us think about content for the NHS Digital Service Manual, and the second because we think there are some aspects of designing and building digital health services which may be unique to health ( see ‘The role of standards in a fragmented ecosystem’).

So what do you think might be unique about health?

Our research suggests there may be a number of dimensions that could be considered in addition to the GDS points and which build on the Design Principles we published as part of the Service Manual and reflect:

• People’s trust in the NHS as an organisation — the NHS identity, the reassuring uniforms, the hospital signs. The NHS identity was designed to help people navigate a fragmented system of services, and understand where to go next.
• The ‘layers of health’. We want to show not only what good looks like, but how you build good. So as well as our links to the work of Gov we believe giving detailed guidance and explicit standards for people working in health is a good thing.
• The ‘context’. Many health services will have greater face to face interaction than Gov services, and those interactions may be in a clinical setting (or a social care setting). So we’ve started talking about ‘designing in care’ and ‘designing for trust’.

In part to test our ‘pyramid of content’ idea, and in the spirit of the new Standard, we’ve crafted some words that build on this.

In terms of caring — we had some feedback from our clinicians about compassion being a key differentiator. This also came up in our recent work on content principles. ‘Caring’ is a core value for most NHS organisations and it’s one of the CQC’s five inspection domains. We’ve used the word ‘caring’ rather than ‘compassionate’ as we think ‘caring’ might be easier to measure.

So we might have a standard that says:

Support a culture of care

Caring is the core business of the NHS. NHS services should provide a positive experience of care or help NHS staff provide a caring service.

All services should make patients, the public and staff feel valued and supported and, as far as possible, involve people in their own care.

And to support this, as well as links to guidance from GDS, we might reference health-based resources from people like CQC…

• The sections on Kindness, respect and compassion , Involving people in decisions about their care, and Privacy and dignity in Key lines of enquiry for healthcare services (Care Quality Commission).

And in terms of clinical safety — clinicians fed back that there should be a separate standard for clinical safety, and that digital services in the NHS should have a nominated clinical safety officer. So we’ve drafted:

Make your service clinically safe

Digital information, tools and services have the potential to cause patient harm.

Make sure that you actively manage any safety risks associated with your content, service and processes.

With supporting text that might be like this…

Your team should be able to show that:

• you have a nominated clinical safety officer — in other words, a clinician with a current professional registration who has been trained in clinical risk management and is accountable for clinical safety
• you are meeting the needs of your most vulnerable users, for example, by allowing patients to request a translator or flagging safeguarding needs
• if appropriate, you work to DCB0129 (the safety standard for manufacturers of health IT software) or DCB0160 (the standard which helps health and care organisations manage the risks of using new or changed health software) — or both
• where appropriate, you comply with NICE’s Evidence standards framework for digital health technologies
• if you provide online primary care services, you have registered with the Care Quality Commission
• if your app is a medical device, you follow guidance from the Medicines and Healthcare products Regulatory Agency (MHRA)

Given the importance attached to open source and interoperability in the Secretary of State’s Policy paper on ‘The future of healthcare: our vision for digital, data and technology in health and care’, we felt this could be a separate point, so we drafted:

Make your service interoperable

In an organisation as diverse and complex as the NHS, we need systems and services which talk to each other. Build for interoperability to share patient records and get data quickly from one place to another.

With supporting text such as…

Your team should be able to show that:

• you maximise flexibility and make content, tools and services available through well-designed APIs to reach more people
• you use agreed FIHR-based APIs to join up care for patients
• where appropriate, you use the NHS number and NHS data registers and comply with NHS clinical information standards
• for disease information in mortality and morbidity statistics, you use ICD-10 (the World Health Organization’s International Classification of Diseases, version 10)
• for electronic care records, you use SNOMED CT (structured clinical vocabulary)

What I take from this

1. It’s plausible there are additional lenses we could bring to bear when we assess quality of digital health services: care, clinical, interoperability. This would be in addition to the GDS standard, and might just be something for a team or an assessment panel to bear in mind, or it might be an extended Service Standard.
2. The ‘pyramid of content’ idea works. Bounded by the NHS identity it sets a standard, explains how to meet it, and brings to life and puts in context things like ICD-10 and DCB0160
3. It reinforces the idea of a Service Manual as a shopfront for a range of standards. As a team we don’t need to be experts on all the things we talk about or link to in that ‘shop’, but we need to know who those experts are across Gov and health.

And how would this be used?

Not sure, hence this post!

We know there is a good and robust process for GDS Service Assessment, and the launch of the new standard explains how this will work. Myself and my team are also GDS Service Assessor trained so hopefully we will play a part in this.

NHSX will also be thinking about how the health system is supported to ensure quality, which I’m sure will include the broader range of health standards, some of which are super-critical.

And whatever the formal process is, I think there’s also space to think about informal coaching, modelling good behaviours, and preparing teams for ways of working that means if they are formally assessed, they’ll already be prepped.

So…

To finish, the new GDS service standard is a brilliant template for considering all elements of a user’s experience of a service. But the NHS is also held to other methods of service and safety assurance. For many people, their experience of the NHS begins with birth, and continues for the rest of their life. There is much more to do, to think about service provision in this context. In some small way I hope this blog has contributed to that thinking.

It’s been brilliant working on this discovery, and we’d love to hear comments from anyone out there who has thoughts on the role of a Service Standard for health. You can find me in Twitter as @ianroddis

And thank you very much to all in GDS who have been supportive of our work around the NHS Digital Service Manual, hope to work with you much more in the future!