My focus as a Senior User Researcher working on the new ‘Register with a GP Surgery’ service was to make sure that we didn’t put barriers in the way of people registering - and to do what we could to pull down existing barriers.

To achieve this, we needed to ensure that the voices of 'seldom heard' patient groups were included in our research and design. The term refers to under-represented groups who traditionally find it hard to access services. One of the guiding principles for the team was “being accessible and inclusive of everyone, in every round of research.”

Using connections across the NHS, and through our own user research community, I reached out and spoke to representatives from key organisations and charities who support seldom heard people, including:

• Doctors of the World 
• Groundswell 
• Friends, Families and Travellers 
• Revolving Doors 

During these discussions, we repeatedly heard of barriers to accessing NHS services because of issues with identification and lack of a permanent home address for example.

Additionally, we spoke to people who would not, or could not, use a digital service. We wanted to make sure that the whole service we are providing (and not just the digital component our team was building) was accessible and usable by everyone.

In the world of remote user research, this required an alternative approach of sending the paper forms out through the post and asking participants not to read them until they were in our video-linked research session.

The ‘Register with a GP Surgery’ service is a new, simplified and standardised digital service that allows a person to go online and register with a GP of their choice as long as the patient lives in the practice's catchment area.

In its simplest form, it is a digital alternative to the paper (GMS1) registration form that people take into their chosen GP practice.

As with any service we deliver, we conduct user research to find out the following:

• is there a need for the service?
• who will be the users of the service?
• how will people learn about the service?
• is the service usable?
• can people achieve their goals by using the service?
• is the service inclusive and accessible to all?

After establishing a clear need for the service, we set to work on the design and delivery of it. This includes forming hypotheses around what the service needs to deliver on to patients, as well as accounting for important operational rules such as allowing for matching people to an NHS record if it exists and ensuring that registrations can be processed by the GP practices’ systems.

It was during this phase that we worked closer with Doctors of the World and Groundswell, to arrange for some of the people to take part in a session that combined learning about user/patient past experiences and trying out our proposed service.

We invited the wider service team to observe the sessions, with the participant’s permission, and made sure we shared learning with the team and wider programme stakeholders. One key thing for user research is to use it for actionable insights, which our team took and acted upon in their design and development of it.

At times, the situations and experiences we heard about were a real life lesson for us to learn from. Groups who often have the most complex health and care needs were telling us they were struggling to access a service that is open to everyone.

They encountered practical problems like not being able to register because they didn’t have identification or proof of address or they didn’t understand the questions on the forms.

There were also concerns about how personal information is shared, which reinforces the need for us to be clear with the public about how the NHS uses data to improve everyone's health and care, including how we protect confidential patient information. All of these real-world examples fed into the design of the new online service.

The people that we spoke to told us:

• that using an online service as a way to register with a GP practice would provide a positive alternative to the paper form because it would allow them to do it in their own space and time
• it would sometimes remove unnecessary trips to the GP
• they would be able to ask other people – friends, family and support organisations – to help them with the form if they required support

Separate to this piece of research, we have received feedback from one of our pilot sites that the digital service is increasing access for marginalised groups, with some of the pilot practices actively going out to visit unregistered or homeless communities to help them use the online service.

Above all, the fact that the service does not require identification was seen as its major advantage. One research participant said: “Not asking for it [ID] makes me feel confident.”

Lack of access to online route 

Many participants noted that an online service would not always be the best option as there can be language barriers, a lack of access to digital devices, the internet, and digital skills.

It was clear that the existing paper service would be able to bridge this gap. We are also working on updating the paper form, so it aligns with the digital service and ensures GP practices gather a standard set of information about new patients.

Additionally, we were told we need to make sure that the service is advertised in the right places so that as many people as possible know about it and can access it if they choose to.

Language

Almost all users told us it was important to make the form available in different languages.

Whilst we don't currently support users for whom English is not their first language within the online service, all of our services use a simple writing style laid out in the NHS Digital Service Manual. Register with a GP surgery is already being tested with online translation tools to ensure people can easily use these tools within the service.

We also learned a lot about the content of our pages that was not related to the language it was written in, but the way that things were written and the phrases and terms that we used.

We learned that the service felt too transactional and that this was something they had experienced in other government and NHS services.

Some pages were felt to be overwhelming, with a lot of text to read. This could be particularly difficult for people who do not usually communicate in English or have difficulties with reading.

Terms such as ‘GP ’caused confusion for some users, who would not know what a GP was, and instead used the word ‘doctor’.

Another example was where we asked a question about someone’s ‘current home address’. Some people felt that this was strange wording to use, as lots of people do not have a home of their own and, even if they have an address to provide, it might not be a place that they would consider their home (for example, a shelter or a friend’s house).

We found that people were more likely to trust the service and use it if the text we used was simplified. We were told that some pages were not always written in the warmest way, which could put people off continuing with the service. To change this, the content team have changed elements of the content – for example, asking questions more directly: “Do you need an language interpreter” or “Which language do you need an interpreter for?” 

Trust

Whenever a service asks a question, it needs to be clear about why that information is needed.

• Why does it need to know this personal information about me?
• What is the intent of this question?
• What is it going to be used for? 
• Why should I trust the NHS to have and keep this information about me?

The team did several content reviews around the question set to make sure that the service only asks what it absolutely must for a registration. In response, a feature was designed into the service to explain why information was being sought.

The user can see why a particular question is being asked using a ‘Why are you asking this?’ drop-down option.

These sessions were eye-opening and often difficult to listen to, as they gave deeply personal stories around the problems experienced.

It was also a privilege to be able to spend time with people and share their viewpoints and insights. We learned so much that we could feed into the service and take back to our wider team and community.

User research is so important in making sure that the NHS is building services that can be used by everybody. We hope by sharing our findings, people will take our insights into consideration and question their design decisions.

Services are never finished. They need to adapt constantly to new learning, scenarios, and feedback.

The ‘Register with a GP surgery’ service continues to evolve, through user research and design iteration, to ensure we can deliver on our core mission: to provide a digital means of registration with a GP surgery for everybody.

If you would like to find out more about the service, please contact [email protected]