Mollie Courtenay, Designer at SH:24

Speaking at Trust & Design #2, 27th September 2017

Transcript: I've been working with SH24 since 2014, so some of the stuff I'll be sharing is that old, and it's just essentially to take you on a bit of a journey through some of the insights that we learned from users doing some discovery work and into how we responded as a service and what we hope to do to continue to optimise our offer. So just to give you some context at the beginning as to what SH24 is and then, yeah, and then I'll explain why it exists, why we made it.

So SH24 is an online service, our primary offer where we started was online STI testing, so we test for chlamydia, gonorrhoea, syphilis and HIV, and the service allows people to go online and order a test kit, have it sent to their home, complete the samples at home, return those Freepost back to our partner lab and then get their results by text message. If there is a reactive result for syphilis or HIV then our clinical team will make the time to have a conversation about that rather than getting a result by text.

So we designed our order journey which you can see in the first screen of the mobile view there, and we're able to see that over 95% of the people that get through the first step, so if they're of age, to use our service, if they're in an area that we're able to service and they accept the terms and conditions, of those people that get through the first step, 95% of those finish and pretty much everybody does complete their order within 3 minutes, and that's something we're really proud of and something that we've spent quite a lot of time on, is the order form. That's the primary touch point, or the initial touch point really, of engaging with SH24, so. We've put some time to that. And I'll explain a bit more in detail about some of that work in a bit.

Since we launched we have also created an opportunity for our service to be able to prescribe and deliver chlamydia treatment to our users, but that wasn't an initial part of the service offer, that's something we've done this year. So why SH24, why did we develop an online service? This was the headline that kind of follows us around, or followed us around initially, South London, particularly in the boroughs we partnered with initially, Southwark and Lambeth, have the worst rates of sexual health - sexual - STI infections in Europe, and clinics are really busy. So this is a photograph taken at 8:30, clinics open at 9:30… they're overrun and struggling, therefore users are struggling also to access the services that they need. So on that, some barriers to access just to kind of give you some more context as to why this service is - we feel necessary.

So to access traditional services you can imagine there's some stigma around being in a clinical service that's kind of near you and that's about sexual health and, bumping into someone you know. Finding a service can be really hard, finding when they're open can be even more difficult because that changes all the time. This is a poster from a service that I don't think is available any more at all but you can see how many different times of day, different days of the week, there's nothing consistent about their offer. And the clinic waiting times are enormous which actually really helped us with user-testing, we could turn up, people would be there for hours, so that was good. Waiting for results through traditional services can take up to 2 weeks, so that's obviously gonna build up your anxiety if you're worried about something. And the private offers - so if you don't want to use an NHS service, if you don't want to wait or you can't wait or, for whatever reason you want to pay - they're very expensive, and they also test for things that you don't really need to know if you've got or not and there's no treatment for, so it's - they're barriers, really. So barriers to providing a decent sexual health service in the current climate is, they're very expensive, there's lots of estate, lots of buildings to pay for, there's so much embedded tradition and culture, but within that there's a lot of change that has happened within how sexual health services are provided and commissioned, so there's sometimes this responsibility dilemma - what's gonna happen next within sexual health? Is it going to say with public health, it it going to move somewhere else? And the - the inflexibility of the contracts that they're in, means that even if there is a decent alternative, they're kind of stuck with what they've got, for 5 years typically.

So the opportunity we saw and our aims are: to improve the sexual health of the local population, so as I said we started local but we had that in brackets absolutely from the start, we knew that we had to build a service that could scale really easily; to improve access and quality of sexual health services; and to increase productivity and reduce costs.

So our approach: we decided to split what we wanted to achieve out into MVPs, so Minimal Viable Products, and the first one being the full STI testing service, the second one being a telephone support service, so, I will talk more about the first one, but I can just give you a quick update on where we are with the next three. So the telephone support service, that was our assumption - we'd develop a telephone support service, I guess because that kind of mimics what's on offer from traditional services. We very quickly found out that users wanted other means to communicate, so, bit more now, really, so we developed both the web chat functionality, and a really smart way of users being able to text our clinicians. A basic contraception service - so we've developed an order form and a relationship with the pharmacy to enable people to order the contraceptive pill, so that's done, and a fuller contraceptive service we're investigating at the moment - how do we grow what we've got, there's opportunities to build in morning-after-pill orders, but we're kind of dependent on finding a good delivery model for that, essentially, because the timing is so tight. It's not the morning after, you can take a morning-after-pill up to 5 days after. And then we've got patches, and rings, and all sorts of self-injectables, and lots going on in the contraceptive world, so how could we build that offer up?

So I'll talk some more about the STI testing service because that's where we've - that's where I'm going with this. So, our approach involved a multidisciplinary team, sticking loads of stuff all over walls, but most essentially being really really near by a clinic. So we were down at the bottom, at 11 Windsor Walk in the room upstairs there, and we were an 8 minute walk, which is probably a bit long, to the Camberwell sexual health service where we'd do loads of user testing, so we were really nearby our users, our clinicians, the receptionist, all the team that we needed to quickly create prototypes with, we could wander over there, go back, iterate, go back over there again, that was great.

So at the beginning of the kind of, design and discovery phase, we had a set of 20 assumptions, but I'm just gonna quickly visualise these 9, and through the discovery process we found this essentially: so, 2 was not validated - people don't want an online account, mainly around their fears of others being able to access information about their sexual health history, that's pretty much - that was pretty much the resounding reason. And that was more fear than, you know - that was the fear.

People are confident in doing the tests at home, there was wobbles around that so we knew we had to do a lot of design work around the offline offer that we - things that we'd send out in the post, how we'd support people remotely, would that be through videos or really smart instructions or support by text, all of those things. And people would be prepared to log into their account for their details - very similar issues, there, with the first one. So we had to rethink that.

So as part of the discovery we ran through loads of insight-gathering exercises, if you like. So we looked at what other services are doing, so this is the Greenwich Health Service, so that screenshot's pretty old now. And their order form, which is scary, right? You can choose your background though, so that's good! They're a great service but their form is not great.

So this - these are two other kits that we decided to order and see what they were like, and to run through the whole process as a user, so to analyse the order form, analyse the kit, analyse the experience of receiving results or not, analyse how I was safeguarded if I entered that I was perhaps young, or had been assaulted or something like that. So we had noticed the complexity of these things and didn't really like it, so that was something we also thought we could do a better job on. A lot of these kits rely on users to know exactly what they're doing, do it in exactly the right order, and there's lots of - you can see, I think the bottom one has about six different pieces of paper, different shapes and sizes.

Audience member: Is that box overtly a sex testing kit?

Mollie: Which one?

Audience member: Free test on the - on the outside

Mollie: Oh I know,

Audience member: "I'm a big STI testing kit"

Mollie: Yeah so that does come in an envelope, it had an envelope round it, yep.

So we spent a lot of time working through our thoughts with clinicians, so that's a meeting in a Southwark clinic, we did loads of focus groups, so this one was about how can we make it as easy and discreet as possible, so we had some focus groups and obviously lots of thoughts here, which I'll share in a moment. We ran some personas which, these are some scrappy versions, but just to see like, we were doing this fairly rapidly. And then we had to do some more technical interface mapping as to where data's going, who's gonna see it, where's it gonna be, in what - you know - who's going to share information with who, and you will notice at the bottom there we have the lab, quite separately, and I'll go into that a bit more.

So the discovery - we ran through those exercises and the main aim for that was to come up with those two items at the bottom, so branding strategy tender and a request for proposals to support our - the development of our service. But also we, obviously came out with so many insights, so I'm just gonna run through some quotes we got, or some kind of generalised quotes, and then how we responded through the design of the service. So as you just pointed out, I wouldn't want my mum/flatmate/partner knowing what I'd ordered, so we don't want a box that says exactly what it is on the tin, so this is our envelope, it's a grey envelope, it has a white label on it, it's discreet.

Then we spent a lot of time thinking about how do we design the interior of the kit to ensure that that doesn't scream - it doesn't associate with you as an individual, so nowhere on the samples did we want the name of the user, we thought we could do a better job, we could do a neater job, essentially, by creating a unique code that we kind of hid within a data matrix code, we thought, if the lab scans it in they can identify the kit. We didn't want them though to be able to identify the user, so we created two codes, so one's for the kit, one's for the user, as SH24 with our data stored in the N3 database we can connect those two up and we can have personal identifiable information linked to that kit ID. Here is just a kit ID, the lab has no idea who owns the kit or what they've done.

So these are just some examples of some early prototypes that we did for that, so the idea being we'd print off one of these A5 sheets, we'd peel off the address label, and then we'd label up each of the kit items before it gets sent out to these, so another thing that the other services might do is they'd ask you to label up or to name your samples yourself, we do that already before they go out. So this is what the lab form - looks a bit better than that at the moment but this is where we were at - so, this is what it looks like when it comes out the printer, and this is what it looks like once the stickers have been used from the top.

So the address label gets peeled off and put on the exterior and then all the little stickers might get put on your swabs, or your blood samples or urine samples, whatever test kit you've ordered, and then myself as user I have to fill in the date, which is today, and then fold over the card and stick it back in with my lab samples back to the lab. So when the lab receive it, they're able to scan in a code on one of the samples which then we receive as a string, and we then associate it back to the user. At that point we're able to text the user and say 'your samples have been received', and we say we'll send your results then in 72 hours. So the next message we'll receive from the lab will be the results string, again with just the kit ID which we can then associate back to the user, so essentially no personal identifiable SH24 information is held outside of the NHS network.

So do I need to write my name on my samples? Funnily enough it's still a question we get, even though we have the samples labelled, and on - this is an image of the instruction card, we do, we have made that as clear as we can I think - but no you don't need to write your name on the sample - some people still try, but we've made sure that we also work with our suppliers to supply tubes and bottles with no extra labels, so there's no temptation, if you like, to write names where they don't need to be.

NHS branding is important but shouldn't feel too clinical. So this is a massive trust thing - we found - so when we were talking about how we brand the service, what feels important for users to be able to associate with a trusted service, we, you know, we tested lots of things but essentially it was - all we needed was the little logo and that eased a lot of worry. It wasn't necessarily a need to see a doctor's face, a lot of the private services have, you know, a doctor in a suit or a jacket that - it doesn't do what this NHS logo does. So it's very subtle on our desktop home screen, there, on mobile it sits alongside the SH24 logo at the top.

So you need to justify why you're asking for personal information. This all came very strongly from our focus group, from a number of people, so what we've - how we've responded to that is within the order form. Every question has a little 'i' button, and within that 'i' button we say what we're going to do with that information, what we're not gonna do with it, and why we're asking for it. It's particularly interesting why people are asking for my ethnicity, and that's something that we need to use to support NHS reporting, so we just have to reply and make that as clear as possible, within the 'i' button copy. So I need to know who has access to my records and why, so within the FAQs we answer that question and we also give a bit more information about how our staff are - what our staff have to be aware of. So, just a quick point to kind of wrap up then, I guess, to be clear that clinicians are users too, so a lot of that has focused on our end users, our service users, but to ensure that we're enabling our clinicians to feel that they're using the secure service, and to ensure that we are delivering the secure service we - this is the log-in for the back-end system so all the clinicians that access that admin tool - so they have to log in with their email password and then a 2 factor authentication code that we send to their mobile, which our users do as well, actually, within the order form, so when they're ordering we verify their mobile number.

And then they also have to have a memorable word, and then there's this warning here…so that gives users access to Admin. So then, just to say, and I have mentioned it already, but beyond STI testing we're working with pharmacies to deliver chlamydia treatment and contraceptive pills, and we also have lots of information on our site that's supporting contraceptive choice, and we're pleased that the BBC sometimes link to that information, so I feel like we've done a good job there too.