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Why accessible design is good design

Josh Healey, User-Centred Design Lead for the Register with a GP surgery service, explains how redesigning the first page of the service made it more accessible for everyone – and how they created a framework to measure impact.

General practitioners (GPs) play an important role in our communities. GPs treat common medical conditions, refer patients to hospitals and act as the first place many go to for health and wellbeing advice. This is why it is so important that everyone can register with and see a GP when they need to.

The author Josh Healey standing in front of a white board

One of the ambitions of the Register with a GP surgery service is to reduce the barriers of entry to healthcare for everyone.

It is important to pause and consider what we mean by everyone. Some of us – myself included – will not face inherent barriers to accessing basic healthcare. This is not the case for everyone.

Healthcare for everyone

Today, there are nearly 56 million people living in England. Within this population we know that:

People in these groups may need additional support to complete certain tasks. Or, they may have a lived experience which affects their ability to engage with and trust health services.

Accessible design is good design

What this means is that when you design something for people with additional needs, it almost always improves the experience for everyone at the same time. If we can give people what they need, when they need it and in a way that works for them, then we can help to reduce barriers for people accessing healthcare. 

Who is at risk of being excluded?

Before launching the Register with a GP surgery service, we had already done a lot of user research to understand some of the barriers people face. For example, not being able to register because they didn’t have ID or proof of address. 

After our beta service assessment earlier this year, we dedicated more research time to better understand the needs of people who:

  • come from historically marginalised groups 
  • have low digital confidence 
  • face healthcare inequalities 
40% of households have at least one person with additional needs.

We wanted to be able to hear from everyone who needs our service and that our designs reflected our diverse audiences. My colleagues Imran Akhtar and Lucy Johnson worked hard to learn how these user groups are affected by healthcare inequalities as well as digital exclusion.

We found that some of these users:

  • have difficulty concentrating for lengthy periods 
  • can get overwhelmed by a lot of text
  • may need extra time to complete tasks 

We also found that some users with English as a second language would often mistake words like ‘options’ with ‘optional’. 

40% of households have at least one person with additional needs. 6 million people register with a GP every year, so it's a reasonable assumption that there are thousands of people struggling to register.

This is why the work Imran and Lucy led on was so important in helping to bring some of the seldom heard voices into the design space.

Re-designing our start page

We wanted to do something with what we had learned. We started back at the beginning and considered how we could improve our service start page (the first page of the service). We could see from our data that this was the largest drop-off point for our users – why was this?

While some of those opting to not continue at this stage would have been for good reasons, our assumption was that for some users our start page presented barriers which were blocking them from getting what they needed. 

Over time, as we had added more features to the service and discovered more requirements, the start page had grown quite big. 

Our hypothesis was that if we made the start page simpler that it would not just improve the experience of users from low confidence backgrounds and marginalised groups but improve the experience for all users. 

We reduced the word count by about 30%.

What we changed

We revisited the basics of good user-centred design and the service standard when looking at our start page. 

After reviewing the page our research and design team felt that we were:

  • asking for too much information too early 
  • referencing niche jargon where it wasn’t needed

David Evans, one of our content designers, analysed the page in what we call a ‘heuristic review’ and saw that while what we asked people for was technically necessary for some users – much of it could be asked later on in the service at the point of need. 

1. UK European and Health Insurance Card (EHIC)

Our content around EHIC and those who need to complete an S1 form (which turns out does not actually stand for anything – it is just called the S1 form) was probably not essential information to be shown here. We wanted to see if this could be moved to later in the service, at the point where we ask overseas users some questions very specific to them.

2. NHS number

The same could be said for telling people how to find their NHS number. While our intentions were to be helpful – this content assumed that you:

  • are going to use NHS login to access this service
  • need help finding your NHS number 

While these scenarios are bound to be relevant in some cases, it is at the expense of making the start page long for everyone. Testing had not shown we needed to show this yet, so we moved this content to the point of need. This is a few screens later where a user is asked if they want to use NHS login.

3. Date of birth

We also told people that we would need their date of birth and name to use this service. On reflection, this is not something unusual to be asked and we probably didn’t need to include it here. We took this out altogether.

We reduced the word count on the redesigned start page by about 30%. It might only seem like the removal of 2 lines of text and a few bits of additional information – but it really adds up.

Excessive content can increase the cognitive load of people trying to engage with our service and is not the best use of digital ‘real estate’. Especially when our access research showed that many people engaging with health already have a sense of anxiety and apprehension before starting a service like this. 

Implementing a performance framework and measuring success

We wanted to be able to measure the impact of our design decisions. The research from our team was robust and our design hypothesis about the changes we wanted to make felt sound. It was also guided by data from the live service. 

However, it was pointed out to us during a Central Digital and Data Office (CDDO) service assessment that we might benefit from a performance framework. Alison Dixon, our performance assessor, kindly spent some time with us to share her experience and suggest how we might go about it. We also found a useful blog on how to go about creating a performance framework

Building the framework helped us all to course correct. 

Designing the framework

Our performance framework includes things like the top-level service purpose, goals, user needs, key performance indicators and design hypotheses. Because the framework considers user-needs, it keeps tech, design and data hypotheses focussed on improving things for the people using it.

We spent several weeks workshopping and refining our framework and used these start page changes to test the effectiveness of:

  • our design decisions
  • the framework we had created

As well as being a useful tool to help us to optimise the service, it was also a reminder of what we are all working toward.

When delivering something at pace and to scale, it can be easy to lose sight of why you started the work in the first place. Building the framework helped us all to course correct. 

Not just moving the problem somewhere else

When we moved the content from the start page we wondered if it would simply move the problem to somewhere else in our service.

For our initial test we wanted to start small so that we could better measure a few things at a time. We felt that the most useful leading indicators we identified from our framework for telling us this were:

  • drop off rates
  • time spent on the page

After a month of making the change, we observed a significant decrease of 11% in drop-offs on the start page without any increase in drop-offs on the pages we moved the content to. 

Similarly, we found that the average time users spent on the start page decreased significantly by 18.5% – with no significant change to how long they spent on other pages.

We did what we set out to achieve.

It looked like our analysis supported the hypothesis that the old content on the start page was problematic and was likely adding cognitive burden to users.

By reducing the amount of time people spend on the start page and increasing the amount of people who continue into the service, we did what we set out to achieve. Without a performance framework in place this would have been harder to measure.

How a framework like this helps in the long-term

Using our performance framework to improve our start page was a useful first step. It provided us with some re-assuring data and gave us confidence that we have built a tool which works for our service.

There is more work to do on the start page – now we have improved it, there are new challenges emerging that would benefit from this approach.

With that said – a performance framework is something which should always be evolving. It does not stop at one test. As a team we will continue to iterate upon and use our performance framework to help monitor our design decisions and to put our users first.

Related subjects

Kerrie Hughes, Lead Service Designer for the new ‘Register with a GP surgery’ service, says registration is more than just paperwork – it’s about giving more people access to healthcare and helping GP practices to provide great care.
Everyone should be able to register with a GP surgery. Senior User Researcher Tamara Farrar worked with seldom heard groups to ensure their needs were considered when designing a new registration service.
Dr Shanker Vijay, GP and Digital First Lead for London, explains why he is championing the national ‘Register with a GP surgery’ service and talks about improvements to the service.


Last edited: 10 August 2023 5:12 pm