Bill Noble – Design in healthcare: A doctor writes…..

At school, I was drawn to advertising or architecture as a career. However, when I explained this to the chemistry and careers master, Mr Moore, he said that I only thought that because of my mother the architect and my father the civil engineer. Then he told me to stop messing about and apply for medical school. So I did, and never regretted the switch, but I also never really got over the thought that, in the end, doctoring is only maintenance, making do, comforting and mending, never truly creative, never leaving something worthwhile behind.

Mr Moore’s views are still typical of many in secondary and tertiary education as well science and the professions. There are two contrasting views of creativity in the world of medical science, not dissimilar to the views we hold about the humanities. On one hand most scientists rarely understand which bits of what they do are truly creative and make a proper difference. On the other, some think they are doing design and anyone can do it as well as trained designers. It can’t be difficult, because science is difficult and it’s not science.

I was lucky in my education; my grammar school still taught woodwork, art and music. There was at time when “the three Rs” were not reading, writing & ‘rithmatic; they were reading, wroughting & reckoning. Literacy, making and numeracy were given equal emphasis in the skills needed for all walks of life. I blame the academics for the damage to creativity education; forever splitting, separating and sequestering to achieve mastery over their subject and their colleagues. I agree with Christoher Frayling who argued that art and design being taught separately since 1837 put art and design outside respectable academic activity.

 

“Research is a practice, writing is a practice, doing science is a practice, making art is a practice.  The brain controls the hand which informs the brain. To separate art and design from all other practices, and to argue that they alone are in a different world, is not only conceptually strange but may well be artecidal.” [1]

 

I’m not complaining about the inventors, biochemical and mechanical engineers who have, often selflessly, created some of the most wonderful tools for doctors to use. In my world, one name stands out. As an employee of the MRC Clinical Research Centre, Martin Wright never benefited financially from his patents for inventions including the peak flow meter, the breathalyser, the apnoea alarm, the respirometer, the random zero sphygmomanometer and the syringe driver [2]. Whatever creative design skills are, Wright had them. My favourite definition of creativity is that of the late Kenneth Robinson:

 

“Creativity is the process of having original ideas that have value”. [3]

 

The most serious consequence of healthcare professionals’ and researchers’ ignorance of design practice is what happens when a traditional medical or nursing practice requires “modernising” or “scaling” or “reforming”. The vernacular version of NHS service redesign with delegation to less expensive professional input can result in the abandonment of patients’ preferences and interests entirely. As a 1980’s GP, one of the tasks that attracted the most gratitude was clearing wax out of blocked ears. The old steel ear-syringe was a magnificent instrument that projected luke-warm water at a pressure sufficient to get behind the offending wax but never enough to perforate the eardrum, provided you screwed the spout on properly. It took me 10 minutes to examine, clear and re-examine both ears, admire the wax floating in the white enamel kidney bowel, dry the ears, hear the effusive thanks and offer advice about objects smaller than an elbow never being allowed to enter the ear canal. As GPs’ status was threatened and demand for consultations grew, ear syringing was relegated out of general medical services, at first given to practice nurses with electric warm water pistols, then denied by the whole NHS in favour of ineffective advice only to drop olive-oil into the ear. Now it will cost you £80 to hire your local pharmacist to squirt water after the oil has failed and you will still need to see a doctor if symptoms persist.

 

 

Vernacular service redesign commonly imposes formulaic management practices from industry with little account of complex modern healthcare contexts. My experience of the worst example was the Liverpool Care Pathway. At a time when “care pathways” were introduced for most surgical procedures to ensure that airline style checklists and specialist’s skills were exploited to the maximum, end-of-life-care was known to be inadequate in UK general hospitals and inaccessible in UK hospices. The Liverpool Care pathway with its tick-boxes, separate medical record and “variances” was intended to guide nurses’ care of terminally ill patients that doctors guessed had less than a few days to live. Well-designed clinical trials take a long time to set up, run and analyse, so by the time an Italian trial had found the pathway to be ineffective,[4] it had already been also found harmful in practice following a NHS-wide roll out by a government review, entitled  “More Care, Less Pathway”.[5] The main problem was that terminally ill patients can surprise a clinician and not die as predicted, so that withdrawing feeding, fluids and some treatment appeared cruel and wrong to their relatives. Clinical teams with little experience of end-of-life-care followed the protocol rather than calling in advice from palliative care services when in difficulty.

When NHS managers and their political masters lacked the expertise and confidence to tackle a problem like a pandemic in 2020, after already having dismantled the network of local NHS contact tracing of infectious disease outbreaks in the Lansley reforms of 2011, they called in management consultants, Deloite and infrastructure corporation Serco. Despite the astronomical £37billion budget allocated to the whole “NHS Test & Trace” two-year project, the combination of smartphone tracing technology and overmanned pop-up conveyor-belt style testing centres was ineffective in controlling the spread of infection.[6] Sadly, similar stories could be told about most outsourced NHS IT systems.

These examples concern me, because designers might have made a better job, with less risk, more attention to the needs of patients and families and at less cost. Even the Medical Research Council, in its guidance to improve assessment of complex interventions in healthcare, including guidance on the development of interventions does not seem to understand the value of expertise in design practice. No references to the design literature or accounts of theoretical frameworks describing creative design appear in their documents for health service researchers.[7]

 

 

The question is, how do we help powerful institutions and the holders of financial resources in the NHS to understand the value and nature of creative design practice in health care development? Creative design methods involve a kind of reasoning, a way of thinking and attention to the needs and views of service users that differ from clinicians’, researchers’ and managers’ ways of working. The UK Design Council’s “Double Diamond” is a start, with its sequence of four Ds – Discover, Define, Develop, Deliver, but it’s not the full story. The way designers take account of the context in which a solution required; the way they interrogate the knowledge and culture relevant to the task of creating a solution; the way they create prototypes and engage in codesign with service users and providers to iterate further versions are all signifiers of good design practice. I also believe that their style of productive thinking, to create something that integrates all the elements required by the brief, is key to their method. Abductive thinking, that recognises patterns of potential success as well as patterns of potential failure, is also required throughout their iterative process of making.

There are examples of good design practice in the healthcare, including some in-house IT systems created by teams that include clinicians like the one that performed a preoperative screening assessment on me in Sheffield. The buildings that Maggie’s Centres build to house their supportive services for cancer patients are diversely brilliant examples of structures dedicated to their therapeutic purpose. The ubiquitous standard hospital bed will take some beating and the resilience of Littman stethoscope means that I have only needed to buy three in the 50 years I needed them.

Growing up in a family that built its own houses and furniture, then living with a family of artists whose thinking is different again, made me aware that we doctors and scientists are not the same as your tribe, even though there is something in common. Enough in common and enough different to make collaboration essential when we get the opportunity to rebuild UK health service systems and NHS estate, that have been so sadly neglected and corrupted in the last decade.

 

 

Biography:

Prof Bill Noble MBChB MD FRCGP FRCP.

Honorary Professor of Community Palliative Care.

Lab4Living, Sheffield Hallam University.

Retired palliative care physician, former GP, former president of the Association for Palliative Medicine, former medical director of the palliative care charity, Marie Curie.

 

 

References:

1. Frayling, Christopher, 1994, Printed Publication, Research in Art and Design (Royal College of Art Research Papers, Vol 1, No 1, 1993/4)
2. Fiona Graham and David Clark, 2005, Special Article, The Syringe Driver and the Subcutaneous Route in Palliative Care: The Inventor, the History and the Implications. Journal of Pain and Symptom Management Vol. 29 No. 1
3. Kenneth Robinson, 2015 https://www.kqed.org/mindshift/40217/sir-ken-robinson-creativity-is-in-everything-especially-teaching accessed 21/2/2024
4. Costantini M, Romoli V, Leo SD, Beccaro M, Bono L, Pilastri P, Miccinesi G, Valenti D, Peruselli C, Bulli F, Franceschini C, Grubich S, Brunelli C, Martini C, Pellegrini F, Higginson IJ; Liverpool Care Pathway Italian Cluster Trial Study Group. Liverpool Care Pathway for patients with cancer in hospital: a cluster randomised trial. Lancet. 2014 Jan 18;383(9913):226-37. doi: 10.1016/S0140-6736(13)61725-0. Epub 2013 Oct 16.PMID: 24139708 Clinical Trial.
5. MORE CARE, LESS PATHWAY A REVIEW OF THE LIVERPOOL CARE PATHWAY https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/212450/Liverpool_Care_Pathway.pdf
6. House of Commons Committee of Public Accounts. Test and Trace update: twenty-third report of session 2021-22. https://publications.parliament.uk/pa/cm5802/cmselect/cmpubacc/182/report.html.
7. Skivington K et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance BMJ 2021; 374:n2061 doi:https://doi.org/10.1136/bmj.n2061