From: DHSC
Assessment Date: 28/07/2022
Stage: alpha
Result: conditional met
Service Provider: NHSBSA (Business Services Authority)
Condition of meeting the standard
In order to meet the standard as alpha, the team needs to:
- define an approach for understanding the needs of all people who may require HRT
- define an approach for understanding the needs of user groups who require HRT and one or more medications, and present a plan for investigating design options in the next stage of Beta
Service description
The government in association with the Department of Health and Social Care has pushed for a private bill to reduce the cost of drugs prescribed to a person undergoing hormone replacement therapy (HRT). It has been advised to cap the charges for collecting these drugs. This motion has been endorsed by the secretary of the state as well as ministers.
Policy has given the direction that a new type of Prescription Prepayment Certificate (PPC) is to be made available to individuals residing in England, which on purchase (£18.70) would give free entitlement to the Drugs for a period of 12 calendar months from the date of purchase. The project delivery date is April 2023.
NHSBSA worked closely with DHSC to design and appraise options to achieve the policy. Ministerial direction was given that a HRT PPC would be delivered.
Service users
- 'Typical’ HRT users
Women over the age of 40 experiencing menopausal symptoms – natural or surgically induced
- Peri-menopausal (most 40+)
- Menopausal (typically 51)
- Post-menopausal (not finite)
Current users typically:
- White
- Middle-class
- Working
2. ‘Non-typical’ HRT users
a. Individuals living with:
- POI - Primary ovarian insufficiency
- HA – Hypothalamic Amenorrhea
- PMDD – Premenstrual dysphoric disorder
- Hormonal Migraines
- Osteoporosis
- Extreme endometriosis
b. Surgical menopause under 40 (hysterectomy)
c. Trans community
d. Ethnic minority groups
Report contents
- Understand users and their needs
- Solve a whole problem for users
- Provide a joined-up experience across all channels
- Make the service simple to use
- Make sure everyone can use the service
- Have a multidisciplinary team
- Use agile ways of working
- Iterate and improve frequently
- Create a secure service which protects users’ privacy
- Define what success looks like and publish performance data
- Choose the right tools and technology
- Make new source code open
- Use and contribute to open standards, common components and patterns
- Operate a reliable service
1. Understand users and their needs
Decision
The service met point 1 of the Standard.
What the team has done well
The panel was impressed that:
- the team is working on a challenging but important service that could impact millions of women. The user researcher on the team is knowledgeable and has used a variety of methods and processes to undertake research to a high standard for the service
- the whole team is involved in user research sessions. It is important to continue this throughout the development of the service, so all team members are tackling the problem space with users in mind
- the team is collecting demographic data from research participants to identify if the research samples are diverse and representative of the service users. They should use this data to inform their research recruitment going forward and widen their scope
- the team have reached out to subject matter experts, widening their understanding and knowledge base to include menopause charities
- the team acknowledged the constraints of not having a discovery and the impact this has had on establishing the user needs of the users
- the team is working with the communications team to ensure the messages and communications materials are researched with the users as raising awareness of the service is paramount for the success of the service. Consider drawing on the expertise of local community champions that can engage with groups who are seldom listened to, for example, English as a second language or members of the trans community
- the team has described ‘typical’ and ‘non-typical’ users . Research had been conducted with a mix of both. Although the panel would argue that both user groups are considered primary users of the service and would not categorise the ‘non-typical’ as secondary users just because of current minimal low numbers
What the team needs to explore
Before their next assessment, the team needs to:
- think about the wider end users of the service and not limit their scope to the typical affluent, white, working women. When pressed about engaging with people outside the existing users the team deemed that it was a policy question. We would like to see the service take more ownership of this as a problem with the current service. We recommend that the team should think more broadly about the primary user group and aim to include more women of varying ethnic, cultural, sociological backgrounds and those living with multiple comorbidities to establish and refine their user needs
- include some proxy users in the research sample and other health professionals that will be instrumental at raising awareness of the HRT PPC such as doctors and health professionals working in sexual and reproductive health
- address the points identified in 2. Solve a whole problem for users
2. Solve a whole problem for users
Decision
The service conditionally met point 2 of the Standard.
What the team has done well
The panel was impressed that:
- the team conducted usability testing was with both patients and practitioners
- the team has acknowledged the need for broader users and steps are being taken to address this, such as expanding the definition of peri-menopausal
- the team undertook research with leading UK menopause charities
- the team had identified and engaged with an extensive range of stakeholders inside and outside the business, and demonstrated a good understanding of where they would need to collaborate closely during beta
- the team articulated clearly what the whole problem was, and where the gaps are. The most prominent gaps identified were
- citizens who are eligible for the service, but do not know about it
- citizens who already use the PPC service, but also were eligible to use the HRT PPC
What the team needs to explore
In order to meet this point, the team needs to:
- define an approach for understanding the needs of all people who may require HRT
- define an approach for understanding the needs of user groups who require HRT and one or more medications, and present a plan for investigating design options in the next stage of beta
Before their next assessment, the team needs to:
- carry out more research to define the problem space for all people who may require HRT - not just white middle class. Define, test and validate their approach for further investigation
- undertake further research into the number of people requiring HRT and one or more other medications. Typically comorbidities increase with age, so there is already a strong likelihood that people needing HRT will also require prescriptions for other medications in which instance the HRT PPC service will not cater to these users. Define, test and validate their approach for further investigation
3. Provide a joined-up experience across all channels
Decision
The service met point 3 of the Standard.
What the team has done well
The panel was impressed that:
- the team has analysed user experience of the current PPC and iterated in the HRT PPC to improve the service journey, particularly in reducing number of screens and incomplete journeys occurring in postcode and nation selection
- the team has challenged riskier assumptions, such as the value of pharmacy channels
- the team already has a relationship with the contact centre, and plans for further research and design iterations
What the team needs to explore
Before their next assessment, the team needs to:
- actively engage more with the DHSC Communications Team to map inroads to this service for a varied user base, and then develop the wireframes or protos to reflect this
- do user testing, perhaps via A/B testing, on experiences of the PPC service versus the HRT PPC to evaluate and justify benefits of a distinct system. A strong enough case has yet to be made for a separate HRT PPC, rather than incorporating this into the current PPC system and iterating that system as part of the project
- understand and map what areas of HRT PPC and existing PPC are duplicated or have gaps, and show how measures are being taken to mitigate this, and reduce inefficiencies. For example aligning content across services, sharing research and findings, monitoring user issues, aligning and sharing key operating procedures where relevant
4. Make the service simple to use
Decision
The service met point 4 of the Standard.
What the team has done well
The panel was impressed that:
- the team has put in place robust design processes, starting with design patterns, carrying out user research, and iterating the designs and these have been documented clearly
- the team has actively questioned and pushed back on imposed design constraints, which means that not all avenues of design have been tested. Keep up the good work
What the team needs to explore
Before their next assessment, the team needs to:
- continue iterating the design patterns, informed by user research, and documenting findings
- share knowledge with the design and research communities across the NHS where relevant
- continue to question whether and how both PPC and HRT PPC can operate side-by-side efficiently and effectively? Document any gaps and crossovers in activities, deliverables and roles across the two services, to build evidence for the future, should this decision be reassessed.
- continue to build close relationships with the PPC team and have free flowing lines of communication to share research, content changes, and findings.
- address the points identified in 2. Solve a whole problem for users
5. Make sure everyone can use the service
Decision
The service met point 5 of the Standard.
What the team has done well
The panel was impressed that:
- the team has prioritised early engagement with stakeholders from telephony and pharmacy to ensure the design scope covers multiple channels
- the team has demonstrated an excellent understanding of internal business stakeholders and organisational areas that are key to the success of the service, and have already begun to build relationships
- the team has clearly and honestly articulated ‘known unknowns’, and they had made remarkable progress in a short space of time in understanding how they might fill those gaps
What the team needs to explore
Before their next assessment, the team needs to:
- make a clear plan for, and begin exploring how users can become aware of the service and prepare for the service
- continue widening the scope of the service entry points, mapping the user groups who qualify for the service, but are not yet aware. The entry points must be wider than gov.uk and nhs.uk
- continue building relationships with organisations both outside BSA, and outside the NHS, who can facilitate wider user engagement with the service
- understand and document the unhappy paths, for example where PPC users are unable to use the HRT PPC users, and use the private beta phase to explore practical design solutions
- address the points identified in 2. Solve a whole problem for users
6. Have a multidisciplinary team
Decision
The service met point 6 of the Standard.
What the team has done well
The panel was impressed that:
- the team has ensured that the working environment was collaborative and open
- the team has made sure that key roles disciplines were well represented by skilled team members
- the team has identified a greater need for user research and addressed this by appointing a senior user researcher, and a Junior User Researcher being recruited
- the team has made sure that a target baseline team will continue to support this service once it enters a live environment
What the team needs to explore
Before their next assessment, the team needs to:
- embed DHSC Policy colleagues more into the multidisciplinary team so that they better understand the user needs and current technical ecosystem within which a HRT PPC service will exist
7. Use agile ways of working
Decision
The service met point 7 of the Standard.
What the team has done well
The panel was impressed that:
- the team is working very much in line with agile methodologies, with ceremonies in place to promote efficient, collaborative and iterative working
- the team has utilised digital tools well to explore and present ideas
- the team has increased agile and user centred design (UCD) buy-in from DHSC Policy stakeholders
- the team are already examining ways of working across UCD and development and quality assurance professions to ensure that work is given visibility across the disciplines
What the team needs to explore
Before their next assessment, the team needs to:
- continue to use agile ways of working, bringing stakeholders closer to the day-to-day work to continually increase buy-in and understanding of user pain points and the challenges of the current system solution
- continue working closely across disciplines, exploring ways to share activities and maintain visibility of deliverables through every stage of the service progression
8. Iterate and improve frequently
Decision
The service met point 8 of the Standard.
What the team has done well
The panel was impressed that:
- the team capacity is being developed to enable different ways of researching, with more people, on a frequent basis, to take place
- the team is testing a variety of user feedback mechanisms and the content of these is consistently evolving, for example allowing users to self-describe
What the team needs to explore
Before their next assessment, the team needs to:
- continue to research and test with users to define future iterations and not be afraid to use learnings to challenge project constraints
9. Create a secure service which protects users’ privacy
Decision
The service met point 9 of the Standard.
What the team has done well
The panel was impressed that:
- the team has based the design on National Cyber Security Centre (NCSC) Cloud Security Principles
- the team has presented and received approval of the technical design to their inter design authority
- the team has considered security implications for the service at alpha
- the team has identified potential threats for the service, and data stored
- the team is employing the design which is using data encryption at rest and in transit to mitigate against identified treats
- the team is using existing BSA process to manage any security incident including data breach
- the team is using Amazon Web Services (AWS) managed services, minimising the need to develop bespoke security
- the team is using Data Dog, an observability service for cloud solution
What the team needs to explore
Before their next assessment, the team needs to:
- demonstrate how customer data and client side data encryption is achieved in private beta
- test the BSA process and in particular for customer data breach scenario
- test security guard rails around use existing telephony system to update the user details
- test how to spot and stop potential internal data leaks
10. Define what success looks like and publish performance data
Decision
The service met point 10 of the Standard.
What the team has done well
The panel was impressed that:
- the team has broadened the core key point indicator (KPI) of satisfaction to incorporate ease, time and choice of using the service
- the team has gathered metrics throughout use of the service; including surveys at dropouts
- the team has undertaken forecasting to establish a comparative baseline
- the team has put measuring in place to identify a need of users to self serve
What the team needs to explore
Before their next assessment, the team needs to:
- test the as-is PPC infrastructure further with diverse user groups, particularly those with additional needs to understand if a separate system is better than just bolting onto what is already there. Success of the service can’t be established until we understand whether this independent system is needed over integration with the existing system
- establish metrics for users learning about the service, such as, where are they currently getting information, what comms are most effective, where are the majority of click throughs originating, and other measurements of site traffic
11. Choose the right tools and technology
Decision
The service met point 11 of the Standard.
What the team has done well
The panel was impressed that:
- the team has presented and received approval of the technical design to their inter design authority
- the team is using AWS managed service, adhering to NHS public cloud first principle
- the team is aligning technology needs with the existing BSA technology stack
What the team needs to explore
Before their next assessment, the team needs to:
- validate the benefit of AWS Fargate to manage web front end by comparing service response time between Fargate and non-Fargate solution and the associated costs
- firm up use of AWS RDS or AWS Dynamo DB before private beta
12. Make new source code open
Decision
The service met point 12 of the Standard.
What the team has done well
The panel was impressed that:
- the team is planning to publish code in open in iterative manner as oppose to a big bang approach
- the team has made sure published code will be available for public use
- the team is working in open and their ethos is to work in open adhering to Digital by Default
What the team needs to explore
Before their next assessment, the team needs to:
- keep code closed where appropriate, to retain control of sensitive code
13. Use and contribute to open standards, common components and patterns
Decision
The service met point 13 of the Standard.
What the team has done well
The panel was impressed that:
- the team is using the NHS prototype kit for accessibility and consistency with other NHS systems
- the team is using common components and patterns from the NHS design system
- the team is using Gov.UK Pay and Gov.UK Notify
What the team needs to explore
Before their next assessment, the team needs to:
- identify common patterns between current PPC and this service and pull them out as a sharable components to simplify merging of the 2 solutions in future
- share learnings and contribute back to the NHS design system
- explore whether any architecture components might potentially be reused from other government services to avoid duplication
14. Operate a reliable service
Decision
The service met point 14 of the Standard.
What the team has done well
The panel was impressed that:
- the team is ensuring as much similarity as possible has been retained in the telephony systems being used, so as to stabilise the journey for call handlers handling data management
- the team is using AWS managed services
- the team has agreed a service level agreement (SLA) and can recover the system within 2 hours in the event of any failure including disaster recovery
- the team is using multi zone deployment, minimising risk of service disruption
What the team needs to explore
Before their next assessment, the team needs to:
- explore alternative user ‘copies’ of their HRT PPC submission which are digitally interoperable, meaning not just simply PDF or screenshotting
- test and prove use of existing telephone system to update user details
- assess the feasibility of auto renewal feature in the current design and how potential blockers could mitigated
3 comments
Comment by Ian Vincent posted on
I feel there is sex discrimination here with this decision. Men prescribed testosterone as hormone replacement cannot access this scheme!
Testosterone has a variety of uses within the body, including improving mood.
I understand testosterone is not licensed as hormone replacement, but that’s exactly what it is!
Comment by Lee Morris posted on
Yes Im on testosterone, male HRT, and I have to get a new prescription every three weeks!
Sometimes i have to wait up to 2 weeks to receive because no pharmacy keeps testosterone in stock anymore, so they have to order it in everytime!
And I agree that it's straight up blatant discrimination against men.
Thanks NHS...
Comment by Michelle Mattinson posted on
It would be nice to be able to actually get access the page online and apply for hrt ppc. The site is closed. Not very good. Very disappointing.