How do you design a public (national care) service?

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In the recent extended blog about the National Care Service (NCS) Bill, we highlighted that the Bill is both a framework bill, leaving much detail to secondary legislation, and that this detail of the NCS will be ‘co-designed’ with the users of services and evolve over time. This work has already started. Co-design has already emerged as a key theme during scrutiny of the Bill at Stage 1, in the Finance and Public Administration Committee, the Education, Children and Young People’s Committee, the Social Justice and Social Security Committee, and at the lead committee on the Bill, the Health, Social Care and Sport Committee.

To support committees in their scrutiny of the Bill, this new extended blog will consider what might be meant by ‘designing’ a public service, and what co-design is or might be, using the National Care Service as an example. It will look at questions like who should be involved in co-design – people who need care and support, any of us, staff working at all levels in health and social care? And at what level should it take place – national, local or both? It starts by looking at how governments have started to use service design in recent years, transporting and adapting the methodology from technology and product design.

There is no definition for co-design in The Chambers Dictionary, but ‘co’ as a prefix is defined as ‘with’, together, joint or jointly, and co-design as ‘to design (something) by working with one or more othersto design (something) jointly (Merriam-Webster). The same dictionary defines ‘design’ as ‘to create, fashion, execute, or construct according to plan.’

This is a fair bit longer than our regular blogs, as there’s a lot of ground to cover and it has become a key issue in scrutiny of the NCS Bill, and so we’ve added a contents popout below:

The Scottish Approach to Service Design

In June 2019 the Scottish Government published The Scottish Approach to Service Design.

The headline vision for this is that:

the people of Scotland are supported and empowered to actively participate in the definition, design and delivery of their public services (from policy making to live service improvement).

The publication is a ‘framework to guide how we design user-centred public services’.

The Minister for Mental Wellbeing and Social Care wrote to the Health, Social Care and Sport Committee in November 2021:

In line with the good practice demonstrated in the development of our approach to delivery of Social Security in Scotland, we will apply the principles of the Scottish Approach to Service Design to the development of the National Care Service. This will ensure that people, and human rights, are at the heart of our approach. We are clear that the NCS must be developed for our people and with our people. The recent work completed by PwC to create plans for a ‘Design Authority’ will support the governance processes and ensure that this is firmly embedded in our work…  I also want to advise the Committee of the publication of a further procurement exercise under the Management Consultancy Framework. This seeks bids for the development of a Target Operating Model for an NCS, delivery of a Programme Business Case, and input to and verification of Current Operating Models for Social Care. These will provide a baseline and framework on which we will build the new system through the co-design approach outlined above.

The Management Consultancy Framework recognises the occasional need for this type of specialist service. The Framework provides access to a range of skill sets and levels and areas of specialism drawn from a team of resources as opposed to reliance on single individuals. This is standard practice in the progress of any such large scale change and provides an independent assessment of the planned change. The Management Consultancy Framework recognises the occasional need for this type of specialist service. The Framework provides access to a range of skill sets and levels and areas of specialism drawn from a team of resources as opposed to reliance.”

The Minister wrote again to the Committee in December 2021, with an update, confirming that KPMG had won the bid to create a Target Operating Model (TOM).

On the day after the NCS Bill was published, the government published a 5-page document outlining what co-design will mean for the NCS.

The document covers engagement already carried out, prior to the Bill being introduced with those with experience of social care services.

The Scottish Government’s ‘primer’ for service design, focuses on the ‘end user’, their ‘service journey’ and the problems that underlie the needs people have with that journey. It argues that ‘if organisations work together to understand the problems in a common way, effective service journeys can be designed’. This is very similar to the UK Government’s approach.

The UK Government, like the Scottish Government use ‘User-Centred Design’. A blog ‘moving from the private to the public sector as a designer’, sets out a bit more about how it is used and how it can be used.

The UK Government has a Service Standard, and uses Design and User Research groups to support service design. It makes no reference to policy areas; from this, it is clear that the design process sits outside policy and policy teams. The process is focused on the end user and the ‘supplier’, and the complex ‘journey’ in between.

There is a lack of clarity about the role in the process of:

  • those who commission, procure, manage and deliver services
  • other stakeholders, such as trade unions, professional associations and academics.

According to information on the Scottish Approach to Service Design web pages:

“There are 7 principles of the approach:

  1. We explore and define the problem before we design the solution.
  2. We design service journeys around people and not around how the public sector is organised.
  3. We seek citizen participation in our projects from day one.
  4. We use inclusive and accessible research and design methods so citizens can participate fully and meaningfully.
  5. We use the core set of tools and methods of the Scottish Approach to Service Design.
  6. We share and reuse user research insights, service patterns, and components wherever possible.
  7. We contribute to continually building the Scottish Approach to Service Design methods, tools, and community.”

The basis for the approach is taken from industry and product design – the Design Council’s Double Diamond model:

Image of the Design Council's "double diamond model, showing 1) Understand the problem and 2) Design the solution, through a four stage process: Discover, Define, Develop, Deliver.

“The principles of the Scottish Approach to Service Design means that organisations responsible for services work together in the problem space to define the problems (engaging fully with users) before moving to solutions.”

Scottish Government

This model is simple, but questions arise. For example, in something as complex as social care – which isn’t a single service – which problem do you start with? How do you break these problems down? Each individual will experience each bit of ‘the system’ in a unique way, and it will depend on them, the knowledge they have, the people they encounter and their very specific needs.

User research is central to this approach to service design, and is the method used to connect the service designers with the people who will use it.

User research

The Scottish Government invest in user research. They say it helps their policy teams

  • “learn about users – their behaviours, motivations and life experiences
  •  design services informed by what they’ve learnt

Without it, you may not know what problems you’re trying to solve, what to build, or if the service you create will work well for users.”

The costs associated with the NCS Bill are contained in the Financial Memorandum. The Financial Memorandum does not contain costs for design work for services nor the costs for ongoing social care and support delivery. Instead, it primarily covers what is actually written into the Bill, providing estimates based on available data. For example, it has sought to estimate the cost of ensuring carers have access to respite, and the establishment and running costs of care boards. However, it does also include estimates for setting up a National Social Work Agency, which isn’t in the bill itself.

Some of these issues have been covered in the meeting of the Finance and Public Administration Committee on 25 October, in which the Committee expressed concern about the financial risks of the costs of the proposals, and what had not been costed. The general concern is that the lack of detail in the Bill makes it hard to estimate costs accurately. The costs of designing, carrying out user and other research and reforming services have not been estimated or included.

The Scottish Government information on user research says:

“user research must focus on how people achieve what the service is meant to deliver. This is different to what people would like or prefer.

If the people delivering the service cannot do what they need to effectively and efficiently, individuals and businesses will experience problems, delays and frustration. The cost of delivering the service will increase.

To design an effective service, you need to research your users’ end-to-end journey and all the ways they interact with your service”

Scottish Government

However, from all of this information, and looking at the case of the NCS in particular, it appears that those who organise, commission and manage services in local authorities and health and social care partnerships, are not included.

When has co-design been used in public policy in Scotland?

Co-design was used in the design of the new social security system in Scotland. There is also a Promise Design School, which is there to connect users and people who deliver services to learn the principles of service design using this methodology in the delivery of the Promise.

For the new Scottish social security benefits, there was the opportunity to start from first principles. With regard to existing benefits, there was a focus on ‘safe and secure transfer’ from the Department of Work and Pensions..

One aspect of the social security design was the creation of the Social Security Charter. Once the Charter had been created, the Scottish Government went on to develop a ‘Measurement Framework’, again using co-design. The summary sets out how analytical co-design  was carried out in this context. It placed the Charter at the centre, with four sections about whether and how commitments in the Charter would be fulfilled.

Social Security Experience Panels were set up to ‘inform key decisions in the design of social security’. The Social Security Directorate published a series of annual reports and other documents describing the methods (survey, focus group and interview); and some further study of these publications builds up a picture of how extensive the work was. These methods are forms of consultation and all appear to have been with social security benefit claimants.

There are clearly parallels between the legislation that set up the new Social Security System and setting up the National Care Service. The Social Security (Scotland) Bill was described as a framework bill; it set up statutory principles, a charter, an advocacy service, for example. The creation of individual benefits was left to regulations. Concerns about a lack of scrutiny led to the creation of the Scottish Commission on Social Security to provide further oversight as secondary legislation was introduced.

The Scottish Government response to the Stage 1 Report on the Social Security (Scotland) Bill chimes with language being used during the scrutiny of the NCS Bill.

“this Bill was developed as a legislative framework to enable the ‘whole story’ of what people need to do to claim what they are entitled to from our Scottish system; to be told in a set of regulations for each benefit. I also wanted to ensure we continued engagement with the Committee and stakeholders as policy developed”

Scottish Government

While public scrutiny of the NCS has not raised any of these parallels, the work on social security provides a precedent for the NCS, although it is worth noting some key differences:

  • A social security benefit is a discrete quantifiable thing, with clear eligibility criteria attached based on quantifiable information about a person’s income.
  • Person-centred social care, if it is to fulfil the NCS principles, would provide a seamless, holistic, rights based approach to someone’s needs, potentially across their life course, with a focus on prevention.

What do we know so far about the design of the detail of the National Care Service?

Steering groups, reference groups, consultants and panels…

In the Policy Memorandum that goes with the Bill, the government says that:

“the Bill creates a framework for the National Care Service, but leaves space for more decisions to be made at later stages through co-design with those who have lived experience of the social care system, and flexibility for the service to develop and evolve over time.”  

Policy Memorandum

They have also established a Social Covenant Steering Group ‘to review plans for co-design and consultation, ensuring that lived experience and the views of people are central in the development of the NCS.’

In the months since the introduction of the Bill, the Scottish Government’s website, invites people to join the process at a national level, through joining a Lived Experience Experts Panel or a National Care Service Stakeholder Register.

The first things being considered in the process are:

  • “information sharing to improve health and social care support
  • realising rights and recognising responsibilities
  • keeping health and social care support local
  • making sure my voice is heard
  • valuing the workforce.”

In a response to the Health, Social Care and Sport Committee, the Minister for Mental Wellbeing and Social Care provided more information on the work of the Steering Group, and how government is working with them. The group has already met a number of times. He stresses the desire to involve those who feel particularly marginalised or have complex needs. The government is also planning to establish a Lived Experience Partners Panel.

In addition, as outlined above in the letter from the Minister for Mental Wellbeing and Social Care, following a procurement exercise, both PWC and KPMG are, or have been, carrying out some work on the design of the NCS.  The use of PWC and KPMG caused some concern amongst some on the Social Covenant Steering Group, as well as with the STUC.  Dave Moxham, deputy general secretary at the STUC said it was:

“inappropriate for those with a vested interest in privatisation to have an input in the creation of the National Care Service.”

Third Force News reported that UNISON ‘claims both these companies have an international record in promoting market mechanisms in health and care services and, that constitutes a conflict of interest’

During scrutiny, trade union representatives have raised concerns about the presence of the private sector in the delivery of social care services, and the contention that not only are some of these companies are profiting from social care provision, but that some are also poor employers.

Are public services a ‘problem’ or ‘problems’ to be solved for individuals?

The design methodology described in the Scottish Approach to Service Design starts with ‘a problem’ or set of ‘problems’ to be resolved for a user or set of users.

Health and care services are made up of the people who develop, manage and work in them: the doctors, nurses, allied health professionals, social workers, social care workers and service managers, care home owners and care at home providers, for example. They work to support communities, families and individuals in the context of complex lives which are also intertwined with other services. Alongside integration has been the push for staff across community health and care to work in multi-disciplinary teams.

The Health, Social Care and Sport Committee have frequently heard in discussions about health and social care integration, that well-run services are about good leadership and most of all, effective, innovative and collaborative relationships across organisational and community boundaries at a local level.

The work of health and social care partnerships is about delivering on policy expectations and statutory obligations. These come from a wide range of legislation and policy initiatives going back decades.  From the National Performance Framework down to the health and care standards, the narrative is now very much about wellbeing outcomes for people who need care and support.

From these four perspectives: multi-disciplinary working, leadership, collaboration across organisational boundaries and outcomes, it is hard to isolate what problem or problems should be focused on in a co-design process. However, in terms of staff, other public sector partners and providers, in the 5-page strategy plan, the government do acknowledge that:

“People working in national and local government and other organisations with experience in delivering social care support, or managing programmes of change will bring a different set of skills and expertise.”

Repeatedly, during scrutiny, witnesses before the committees have called for full involvement in any co-design process on the detail and secondary legislation. Some have also pointed out that many of the issues and required reforms have been discussed and consulted on at length already over a number of years, such as the call for sectoral bargaining and a focus on fair work, commissioning, recruitment and retention of staff, for example.

It is also worth remembering that the people who work in health and social services comprise quite a large proportion of the Scottish population. They are all also using those services to a greater or lesser extent. In time, it is likely that all of them will as they age and require more support to live as independently as possible. As care staff said at an informal session with the Committee in Aberdeen. ‘This national care service will be for all of us here’.

In terms of the NCS, the Bill mainly makes provision for structural change – the transfer of powers from local government to central government, and the Committees scrutinising the Bill are regularly hearing in evidence that the detail, the secondary legislation and the services are all going to be developed through co-design. This has caused some consternation for the majority of witnesses, even though all support the principles for a National Care Service set out in the Bill.

There are, of course other ways to approach improvement and change in how services function and are delivered. The Improvement Service support local authorities in Scotland and Healthcare Improvement Scotland support health and social care organisations to redesign and think about continuous improvement cycles. At a community level, an assets based model or approach is often used. It doesn’t start from a ‘problem’, but looks instead at what strengths are to be found within a community, usually a geographic community (rather than a community of interest or a specific community, such as those with protected characteristics).

So, where to direct work on design, improvement, development of public services is multi-layered, and this has possibly led to some of the uncertainty about the meaning of co-design in the context of the National Care Service.

Collaboration, Co-design and Co-production (and ‘Consultation’) in the Bill

Some of the main criticisms of the Bill have been about the lack of detail and the apparent vagueness of the language used. There are a range of perspectives about what ‘co-design’ means in practice. The straightforward response to the lack of detail is that this is a framework bill, providing the solid basis for co-designed solutions to inform the secondary legislation and eventual social care and support services. But respondents to the Call for Views and witnesses appearing before Committees have a range of concerns that they ask for more detail on, such as:

  • the potential transfer of powers for substantial functions from local government to Scottish Ministers without any timeline
  • the make up of care boards and who will have be represented
  • profound uncertainty for thousands of public sector staff over their future
  • the future of integration
  • a lack of detail about how the principles of the National Care Service, such as the adoption of ‘a human rights approach’ and fair work could be met
  • the gaps in the Financial Memorandum.

Considering responses to the Committee’s call for views, and from listening to the various Committee meetings in recent weeks, it is clear that there is some conflation and confusion from different stakeholders around the concepts of co-design, collaboration and co-production and the terms have sometimes been used interchangeably.

Many respondents to the call for views refer to the co-design process, co-production and collaboration in differing contexts, but seeming to be talking about the same thing.  As committees near the end of the Stage 1 evidence-taking process, the following definitions might prove useful in explaining the difference between these concepts:

  • Co-design (MIND) “This method consists of people with the relevant skills and experience coming together to create a tangible ‘product’ such as training materials, information booklets, a new service, organisational policies, and service specifications.”

It originally referred to a process involving customers and users in the development of products or services. In the Scottish context it combines user research, which helps to define the problem that requires a solution. A range of activities and processes can then be used with people in the design process.

As described above, in the methodology of the ‘Scottish Approach’, this combines a number of research methods – survey, focus group, user research and interview.

‘Co’ comes from the Latin and according to the Oxford English Dictionary, it means in a ‘general sense’, ‘together’, ‘in company’, ‘in common’, ‘joint, -ly’, ‘equal, -ly’, ‘reciprocally’, ‘mutually’.

  • Co-production (Co-production Scotland) happens at a local level, working closely alongside geographic communities and communities of interest within the local context to find the best solutions for those communities – the solutions emerge from the work done together.
  • Collaboration is a much more general term, but is often used in discussion about integration, and collaboration at a local level between bodies: health boards, local authorities, integration authorities and the third sector. Integration isn’t a necessary condition for collaboration, but collaboration is essential for integration to work.

Consultation could be the fourth ‘C’, a term most are familiar with in the context of public services, legislation and government. In these contexts, it is about collecting and collating the views of people to shape or improve an idea, set of proposals or a service. In various places in the NCS Bill, there is a duty to consult with stakeholders, such as prior to any transfer of children’s or justice social work services.

Where next…

It will be interesting to follow the progress of this co-design process for the National Care Service. This blog has sought to highlight some issues about the approach and the extent to which social services – complex and intertwined – can be successfully re-developed using co-design.

Members and Committees are clearly interested in what is being designed through this co-design process, and therefore what opportunities there might be for the Parliament to follow the process more closely.  As the Bill moves through its parliamentary stages, it is clear that these issues and questions on co-design will continue to be raised.

Anne Jepson, Senior Researcher, Health and Social Care