Improving health outcomes for people with learning disabilities

In detail

What are reasonable adjustments?

In 2010 the Equality Act stated that organisations, including the NHS, must make services accessible to people with disabilities as they are for everybody. These are called Reasonable Adjustments.

Examples of reasonable adjustments include making sure there is wheelchair access in hospitals, providing easy read appointment letters and giving someone a priority appointment if they find it difficult waiting in their GP surgery or hospital.

The Confidential Inquiry(opens new window) into premature deaths of people with learning disabilities found that:

1. The lack of reasonable adjustments was a contributory factor in a number of deaths.
2. GP referrals commonly did not mention learning disabilities, and hospital ‘flagging’ systems to identify people with learning disabilities who needed reasonable adjustments were limited.
3. There is a need for clear identification of people with learning disabilities on the NHS central registration system and for this information to be made available to care professionals in healthcare record systems. Merely identifying that a person has learning disabilities is not sufficient - this information needs to be supplemented by a statement of the reasonable adjustments required.

The problem

Reasonable adjustments are therefore hugely important to providing better care to people with learning disabilities. However, the mechanisms for making it clear to health professionals which patients require reasonable adjustments were not satisfactory. That is why the reasonable adjustments project was created.

It's late in the day

I was brought into the team in the latter stages, as lead interaction designer to replace the previous design resource. I inherited the project in an unusual state. The project had been in progress for many months and they were close to launch. However, some stakeholders had strong views on certain parts of the user experience and the previous designer had struggled to get them aligned on the best path.

With that in mind, I had to not only re-work a core user journey (creating an RA flag) but also had to rebuild relationships within the team. Get people bought into a user centered design process and get them to understand that whilst their professional and clinical opinions are important, we must foremost design based on user needs.

Prototyping user journeys

I was handed a Bootstrap prototype to iterate upon. The design system in place was already agreed. It was using the same look and feel of SCRa - the parent application that reasonable adjustments would sit within. I had a few weeks to tidy up some areas of the prototype, UI and interactions, but primarily my focus was on the 'Create an RA flag' user journey. This was the cause of concern for most stakeholders. It hadn't tested very well and the project team felt it needed to change. The previous designer had attempted a number of solutions before me but was unable to make any progress.

Lose the modals

The first task was to run a heuristic evaluation. With fresh eyes, I ran through specific tasks and noted areas which I felt could be improved. I discovered that the original prototype was heavy on modal windows, especially for multi-step user flows. It felt counter-intuitive to take a user out of a normal page flow to complete a step-by-step process. Plus, modals are never great on mobile and SCRa was to be used across various devices. I refactored the user journey to utilise the available real estate, rather than condense elements into a modal.

Usability findings

We conducted a few rounds of usability testing. We spoke to 10 users via WebEx and asked them to complete a series of tasks (on desktop) to gain feedback on the RA flag prototype. Users were a mixture of specialist roles: General nurse, Learning and disability specialist and nurse, Pharmacists, one admin staff.

During usability testing a number of issues were discovered with the existing flow.

One thing per page

Based on the findings from usability testing, I set about redesigning the create a flag journey. I broke the flow down into one thing per page, so that users could focus on the information that they had to input. I also introduced a clear indicator of what page and what step the user was on so that, for example, we could negate the issue of users entering adjustments on the impairments page.

Type-ahead for adding adjustments

On the add reasonable adjustments page, I explored various ways of making it clear how to add pre-existing adjustments and also allow users to add their own generic adjustment. I opted for a type-ahead component with dual functionality. It's a common web component, used in popular search engines. It allowed users who preferred to browse lists to begin typing a reasonable adjustment and be shown suggestions based on their input. They could continue typing or scroll up and down the list, select the adjustment and add it to a repository. Then repeat the process to add multiple adjustments all within one page.

It also allowed users who wished to add a generic adjustment, one which is not within the library, by typing it out and using the same add functionality. There were concerns from the clinical lead and product team that users of this system would not understand this. I countered that it's common a experience across digital systems, however, we should put this in front of users to test this within this context.

Further iterations

In a second round of usability testing we found that whilst the type-ahead solution was understand, easy to use and well received, the clinical view was that reasonable adjustments should still be present in a list to allow browsers to read through a list, as opposed to searchers who would simply use the type-ahead. I made a case to the team that the component I had created allowed for both those use cases.

Trade-offs

With most design projects, trade-offs are common. Aligning what is best for the users with strongly opinionated stakeholders. With this project I had rebuilt the relationships between design and product / clinician, but I felt with the deadline looming that I had to make the trade-off by adhering to clinical viewpoint.

I created another iteration of the page which presented the type-ahead first, followed by a component which allowed users to browse a list of categorised reasonable adjustments and make a selection that way. Much like any e-commerce site allows. It meant that we could deliver the final prototype (after a final round of usability testing) within the tight timeline and put this into delivery.