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How do users get forgotten?

Simon Davis, a senior user researcher who works across our screening programmes, explains how important it is to get stakeholders involved in designing services that truly meet peoples’ needs.

As part of the Digital Transformation of Screening Programme we are currently replacing outdated systems to help ensure breast and cervical screening services run as smoothly as possible.

Senior User researcher Simon Davis sits at his desk.

To build effective services that meet both the needs of patients and staff, I need to reach out to a wide range of stakeholders.

This includes NHS England and Improvement who own the services, Public Health England who commission the services and the people on the ground who run the services – nurses and radiographers.

I play a part in making sure that in creating new systems we are not creating new problems for any of our users.  We don’t want to create a service which makes one user’s job easier but another user’s job harder.

We want to help our stakeholders understand that user centred design is a tried and tested process of building clinical or patient facing services that solve problems for users.

Highlighting these benefits and the impact it has on the future of services can help bring stakeholders on board.

Fighting assumptions

We sometimes find that those who work in an area are so experienced with working with the existing services and hearing feedback from professionals in that space, they feel confident they already know what the service needs.

However, a user centred design approach can help challenge that and dig a little deeper to discover what our users need, which often differs from what they say they want. We need to make sure we are solving the right problem.

The fact that stakeholders used to work or currently work within a screening service can be a double-edged sword.

It is helpful in that they can help us understand the context that users work within and they can have great connections with the staff user base which helps us reach out to a lot of people.

Comparing a stakeholder's operating practices in the capital to another area like Norfolk or Stockton-on-Tees reveals major differences.

However, we often find that staff operate in very different ways in varying locations. For example, health care in London is often delivered differently to the rest of the country because of its dense and diverse population, and its broad range of hospitals and services in a small geographical area.

So comparing a stakeholder’s operating practices in the capital to another area like Norfolk or Stockton-on-Tees reveals major differences.

A stakeholder might have in-depth experience of one part of the process, but we need to help them to understand the full process and context. For example, some of our stakeholders in cervical screening are nurses, but their experience of running screening will differ from users we speak to in other care settings such as prisons.

Why do we need to reach out to staff users?

We have found that in different parts of the country they don’t necessarily follow a standardised process or guidance (such as planning clinic and staff capacity for Breast Screening) as it just doesn’t work for them. A stakeholder might say they should not be working in that way because they are not following best practice – but the reality is that they feel that they need to work in that particular way to meet the needs of their users.

We therefore find that user research findings can clash with our stakeholders’ experience of the service or what they have heard from colleagues. This can cause some tricky conversations, challenging beliefs which means that a user researcher may be met with a defensive response such as: “You’ve spoken to the wrong users” or  "Why do you need to reach out to staff users? I work in the field and I can tell you how it works."

It is important for the team to understand why any variances exist and to convey that back to the stakeholders and help the programme understand the full landscape of the service.

Our user researchers must ensure their user research is robust, extensive, detailed and communicated effectively. We need to explain our analysis and reporting methods, not just our methods for gathering data.

A radiographer takes a mammogram of a woman attending a special clinic

What are our stakeholders' priorities?

We must remember our stakeholders have their current workload too. Many are currently delivering healthcare or working on other projects and have their own stakeholders. This means they can come to the team with other priorities such as needing to deliver increased uptake of a service, improve a certain part of the service or achieve their key performance indicators.

This has been especially prevalent in the wake of COVID-19. Clinical services are trying to restore services or catch up on patient backlogs. Our stakeholder users can be facing pressures both with running clinical services and caring for patients.

Our role in reviewing in context can reveal issues with the wider service beyond the scope that is under review.

What can we do?

There are several ways we as user researchers can support our stakeholders to understand our user centred design process. It is a relatively new approach for digital delivery, so we should expect to take time to help people to understand the value of applying these practices. Even our team needs continuous training in user centred design.

Helping stakeholders understand our approach

Working in NHS Digital, we invited stakeholders to user research sessions so they can observe people’s behaviour interacting with services and to hear the feedback first-hand.

We have also got stakeholders involved in analysis workshops, especially helpful for those who couldn’t attend any research, but also giving that overview of all the sessions, giving them the opportunity to be involved in coming up with the conclusions and themes that come out of the sessions.

We are trying to understand why people don't come along to screening as some are reluctant even though they know it's important.

It’s really worth actively involving stakeholders in the research and collaborating in the analysis to ensure a shared view and advocacy for the recommendations. It has been harder to involve additional people in screening user testing because some users understandably feel uncomfortable about a lot of people attending a session. It’s a sensitive subject for our patient users.  

We are trying to understand why people don’t to come along to screening, as some are reluctant even though they know it’s important. It’s really helpful for us if our commissioners also build that understanding and get a full picture of the emotional state and context for patients

Involving stakeholders

We not only involve stakeholders by getting them to attend user research, we also invite them to get involved in the mapping and blueprinting. This is a design process –drawing out a visual of what people actually do. For instance, if a nurse works in a GP practice and needs to screen people, you need to understand the process to do just that and look at the challenges.

It really helps us when stakeholders appreciate the problems across the whole service – not just understanding the staff process but also patients’ user needs (both practical and emotional) and context.

What we learnt
  • state the boundaries of user centred design to avoid confusion with other disciplines in the delivery team. This process is not intended to replace good business analysis and service design. It's not a tool to replace the elaboration of scenarios and requirements
  • get stakeholders involved in both the process of user centred design and service design so that they have the confidence in the recommendations, understand why some previous assumptions may have been challenged, and why that matters

A good point of unity

Recently we have been working with working with stakeholders from NHS England and Improvement and Department of Health and Social Care and we are all agreed that clinical risks are of high importance. In screening it is vital to ensure our patients get the care they need and no patients are missed. All members of the team are looking to avoid clinical risks so this can be a good point of unity.


Involving stakeholders in the analysis helps us ensure there are no gaps in our findings. Building up trust by running analysis workshops with the stakeholders and reviewing the findings together means we come to conclusions together that we can all have faith in.

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Last edited: 23 December 2021 11:51 am