New design rules for driving innovation in access to secondary care in the NHS

BMJ 2008; 337 doi: (Published 15 December 2008) Cite this as: BMJ 2008;337:a2321
  1. Hugh Rogers, senior associate, service transformation1,
  2. Lynne Maher, head of innovation practice1,
  3. Paul E Plsek, consultant on innovation and complex systems2
  1. 1NHS Institute for Innovation and Improvement, Coventry CV4 7AL
  2. 2Paul E Plsek and Associates, 1005 Allenbrook Lane, Roswell, GA 30075, USA
  1. Correspondence to:
    H Rogers{at}
  • Accepted 4 October 2008

Although access to secondary care in the UK has improved, more still needs to be done. Hugh Rogers, Lynne Maher, and Paul Plsek describe how understanding the unwritten rules could help us move towards more radical redesigns

Delays in access to health service have been one of the public’s top concerns and the focus of major political reform in the United Kingdom for many years.1 2 Waiting can have an important clinical impact; for example, delays in access to diagnosis and treatment can increase the likelihood of preventable complications, creating unnecessary risks for patients.3

Progress towards meeting national targets has been substantial but has been achieved largely through incremental change and expanding capacity. The most recent review of the NHS notes the need to accelerate change, in view of factors such as the rising expectations of the public and the development of our information society, to provide what patients want—personalised care.4

The US Institute of Medicine’s Committee On Quality And Safety In Healthcare recommended the use of frameworks based on simple rules to guide the complex changes that are needed to transform health systems.5 Simple rules have also been successfully used to guide major improvement initiatives in England (box 1).6 7

Box 1 “Simple rules” developed in the Cancer Services Improvement Partnership6 and Improvement Foundation/NHS Institute for Innovation and Improvement7

High level change principles for cancer services
  • Redesign the system of delivering care to improve experience and outcomes for patients

  • Ensure that patients and carers remain at the centre of the redesign process

  • Enable their views to form the basis of service improvement

  • Focus on the patient and carer experience across the whole patient journey

High impact changes for practice teams
  • Promote self care and self management of patients

  • Improve management of patients with long term conditions

  • Improve access for patients

  • Improve care for patients by redesigning roles in general practice

  • Use data and information to drive improvement

  • Improve care through systematic review of patient feedback

  • Avoid unnecessary follow-up in primary and secondary care

  • Provide services closer to patients

  • Maximise use of practice based commissioning

We aimed to find out the rules or assumptions that currently determine the design of access to secondary care systems in the NHS. We then used these findings to develop a new set of rules that could lead to systems for access that are truly based on the wants and needs of patients and carers. Adopting such rules could be one way to transform access to health care.

Methods and outcomes

Identifying “design rules”

In two separate workshops with clinical and managerial leaders of programmes to improve services, we asked participants to tell stories about current routes of access to secondary care and to extract the principles and “design thinking” behind these processes.

We then asked the same groups to identify design principles that would be more desirable. This process created an initial set of more than 50 items, which we clustered by theme and condensed into sets of simple rules describing most actions that take place in accessing secondary care. The two groups differed in composition yet generated strikingly similar sets of principles.

Illustrating the rules

To illustrate how these rules related to real care pathways, we used three patients’ stories to highlight how the rules defined key steps. Varying scenarios were used to ensure that the rules worked in different social and clinical contexts. The story shown in box 2 describes a hypothetical patient seeking dermatological care in a scenario typical of many places in today’s NHS. The other stories (see featured an older Asian man with diabetes whose daughter has to help him with access, and a young man in pain caused by a renal calculus. Each clinical scenario was reviewed and validated by a relevant specialist (for example, a dermatologist reviewed “Ginny Jones”). For each case, we then wrote a new story to illustrate how the pathways might be transformed by using the proposed new rules (box 3).

Box 2 Ginny Jones: a patient’s story in the traditional system

On a Monday morning, Ginny Jones (age 34, single, works in London investment banking firm, commutes daily from Sussex) shows a co-worker a large mole on her abdomen that has grown irregularly and discoloured over the past year and has now started to itch.

After hearing how her colleague’s aunt died of skin cancer, Ginny is shaken and rings the general practitioner’s surgery in her village. The receptionist is friendly and concerned, and tells Ginny that she can come in any day, but politely notes that the surgery closes at 5 30 pm. Ginny speaks with her boss, who also expresses concern, and they agree that she will take the morning off on Thursday, after a big meeting with the team from Brussels. Ginny finds it hard to concentrate—more stories from well intentioned friends do not help (rules 1, 2, 5).

On Thursday morning she sees the doctor, who confirms that the mole should be checked by a dermatologist, but tells Ginny that it is no use worrying until more tests are done. The practice receptionist arranges an appointment with the dermatologist 6 days hence in a slot that opened due to a cancellation (the next available slot is 13 days away). The date and time conflict with an important conference call with the Brussels team (rules 3, 4).

Ginny turns up early for her dermatology appointment, but waits for 45 minutes past her appointment time. The dermatologist excises the mole and tells Ginny that he should have the lab report in about three working days. He is obviously rushed as the clinic is running late, so offers little information (rule 5).

The dermatologist’s secretary rings Ginny after three days and says that she needs to come to the clinic to speak with the doctor. Ginny arranges a booking for the next day. Although she will miss another project meeting, it seems serious, and her team are understanding (rule 2).

The doctor delivers the bad news: the mole is a malignant melanoma. He explains that this type of cancer can spread and a further wide excision operation is needed. Fortunately the mole is only 0.5 mm thick, so the chance of cure is high, but Ginny will have to go to the plastic surgery department in the nearby teaching hospital to have the operation. The dermatologist dictates a letter to the plastic surgery unit, and promises to fax it to avoid delay (rules 1, 5).

As she leaves the clinic, Ginny feels lost. She would have liked to ask more questions, but the doctor seemed so busy that she didn’t feel she could. The following Monday the plastic surgery unit offers her an appointment for that Thursday. She notes that this is the date of the final report meeting in Brussels, but accepts the appointment anyway.

Note: cycle time to this point is 13 days; all but three days of which were dictated by the system. In other words, the system imposes 10 days of cycle time.

  • The simple rules that seem to be the basis for the actions in each step of the story are indicated in parentheses—these rules are shown in full in the table.

Box 3 Ginny Jones: a patient’s story in a proposed new system

On a Monday morning, Ginny Jones (age 34, single, works in London investment banking firm, commutes daily from Sussex) shows a co-worker a large mole on her abdomen that has grown irregularly and discoloured over the past year and has now started to itch.

After hearing how her colleague’s aunt died of skin cancer, Ginny is shaken and rings the general practitioner’s surgery in her village. The receptionist says that she can come in any day, noting the practice’s evening hours. She also suggests that Ginny could do some self-assessment on the NHS Direct website, with assistance from one of the practice nurses if she wishes. Ginny sets up a telephone appointment with a practice nurse later that day. Ginny sees that her mole looks and feels much like the descriptions and photos on the website. The practice nurse is comforting and offers to book Ginny directly into the dermatology clinic. Although slots are available tomorrow, Ginny has a lot to do to get ready for a big meeting with Brussels on Wednesday, so she selects a convenient time on Thursday evening. Ginny finds it hard to concentrate—more stories from well intentioned friends do not help (rules 1-5, 7).

Ginny turns up early for her booking in the dermatology clinic, and is seen about 5 minutes after her appointment time; the nurse notes this delay and apologises. The dermatologist excises the mole and tells Ginny that he should have the lab report in about three days. He chats with her about her questions while removing the mole. Noting that she is computer-savvy, he prints out addresses of websites where she can read more. He provides her with the clinic’s email address, where she can send questions when they occur to her. He clarifies that he may not always be able to personally answer all emails, but that someone from the practice team will always respond. “And, of course, there is always the old-fashioned way of ringing us up,” he mentions (rules 1, 7).

On Monday, the dermatologist’s secretary emails Ginny that her test results are ready and that the team would like to discuss some concerns with her. She offers Ginny the options of booking a telephone conversation with the dermatologist, coming in for a visit, or giving permission for someone from the team to call. Ginny immediately phones the clinic and asks for a telephone consultation later that morning (rule 5).

The doctor rings at the appointed time and delivers the bad news: the mole is a malignant melanoma. The doctor explains that this type of cancer can spread and a further wide excision operation is needed. Fortunately, the mole is only 0.5 mm thick, so he points out that she should be concerned, but not alarmed, since the chance of cure is high after this surgery. He also explains that alternative treatment options are available and asks if she would like to come in and talk about these options. She says that she would like to do this (rule 2).

The doctor mentions that information about these options is available on the website that he has just sent her in an email, and Ginny could review these before her visit. He explains that he realises that this is serious news and he asks if she is OK for the moment, or would she like to speak to one of the practice nurses. Ginny affirms that she is shaken, but says that she is at work and has understanding colleagues. The doctor transfers her to the practice receptionist and Ginny books a 20 minute slot for a consultation the day-after-tomorrow. She notes that the doctor mentioned she might need to see a plastic surgeon at the local teaching hospital and wonders if she should ring them now to book an appointment. The receptionist confirms that they will be able to do that when she comes in and that consultation slots are generally available on the same day (rules 1, 2, 4).

Over lunch, Ginny begins reading the websites about treatment options and prints out several months of her diary to take with her to the consultation so that she can discuss scheduling options. She thinks to herself, “I’m coping like a financial analyst, aren’t I?” But, then again, that is who she is.

Note: cycle time to this point is seven days, three days of which were controlled by Ginny’s desire to wait until after her meeting to see the dermatologist. The system imposes only four days of cycle time; a 60% reduction compared with the previous story.

  • The simple rules that seem to be the basis for the actions in each step of the story are indicated in parentheses—these rules are shown in full in the table.

Further development

To develop this work we invited 12 colleagues with specific expertise in improving the quality of health care from a range of communities—patient, primary care, secondary care, and whole strategic health—to act as an expert panel. Ten experts agreed to work with us. Using a Delphi technique the expert panel reviewed the rules and the illustrative clinical scenarios. The panel was asked whether the seven current simple rules and the associated stories captured the typical current approach to accessing secondary care in the NHS, and whether the seven new simple rules would yield desirable and innovative approaches to improve access.8

The simple rules were adjusted according to the comments received and were circulated again to the panel. The second round of comments led to substantial agreement between members of the panel and the simple rules were revised to reflect all the advisers’ views, yielding a final list. Following the model established in the US Institute of Medicine’s report, the table describes the current, traditional system as a set of seven implicit rules of system design, and contrasts each existing rule with a proposed new one.5

Traditional and proposed new rules for access to healthcare

View this table:

Box 2 shows how events along the patient’s journey and the behaviours of the service user and care providers can be explained by the seven old design rules; box 3 revisits the story of the dermatology patient, but in a system in which the proposed new rules are the shared mental models. An infinite number of similar narratives could be constructed based on other stories of how service users experience access to care in the current NHS.9 10We have focused on the everyday system of access to secondary care—different design rules might apply in other settings, such as trauma or emergency.

We have used the terms “design rules,” “assumptions,” and “mental models,” rather than “simple rules” as used in the Institute of Medicine report and in publications on complex systems.5 11 The items in the table are stated in far from simple terms, and the comments from the expert panel in the Delphi process tended to embellish, rather than simplify, the items.


What are design rules?

Complex systems can be described in terms of structures, processes, and patterns, which are the result of implicit design rules, or mental models, such as those in the table.12 13 14 15 16 17 These rules might not be formally written down but are shared somehow within a social system. Common approaches to access to health care throughout the NHS can be interpreted as evidence of the existence of shared design rules. The test of the validity of an explicit set of design rules lies in the extent to which such rules explain the behaviour of the system under normal conditions.15 16


Innovation can be defined as any new idea for change in the system.18 The system can be improved by changes in structures (maintaining a single integrated care record accessible to all relevant health professionals, for example), processes (letting patients take and record their own blood pressure rather than having an appointment at the doctor’s surgery), and patterns (listening to patients’ stories for longer before interrupting with questions). However, such changes do not alter the basic design rules of the system. Deeper, radical, more fundamental innovation occurs when we alter these underlying rules.5 17 19

The system changes that we imagined in the narrative shown in box 3 are not the only set that could arise from the new design rules—our purpose is to provoke innovative thinking, not constrain it. The traditional rules are intended to represent current care in most organisations, although much laudable work goes beyond these rules. Some examples of innovations in service delivery that have already challenged traditional rules are listed below.

  • The implementation of “Advanced Access” in primary care, in which a patient may be seen by a nurse or allied health professional rather than a general practitioner (rule 3).7

  • The recommendation to increase the reliability of care through care bundles was a key recommendation in “10 High Impact Changes” (rule 6).20 This approach was based on experience in several improvement programmes within the NHS. One example is a care bundle to reduce surgical site infection by ensuring adequate management of hair removal, prophylactic antibiotics, skin preparation and maintaining normothermia through surgery.

  • The expansion of online information services (rule 2).

  • The expert patient programme (rule 1).21

However, these examples are still at the level of tested innovations, and do not yet represent widespread mainstream practice. The natural trend towards innovation could be accelerated by explicit recognition of traditional and new design rules. Clarifying the design rules, as we have done here, creates the possibility of an actively supported programme of innovation in NHS service delivery to build on (not negate or replace) the natural, evolutionary processes.


We recommend that primary and secondary care providers commit to working together to transform access to care along the lines of the proposed new design rules. This action is aligned with UK government policy, desired by the public, and consistent with the aims of clinicians and managers. Following the lead of the US Institute of Medicine report5 we offer some specific recommendations.

Firstly, commissioners should require and commission for innovation in access to services. The proposed simple rules can serve as a framework to drive thinking about commissioning projects. The framework could also be used to evaluate existing innovative practices and set local goals for the future.

Secondly, providers should use the proposed design rules to differentiate themselves when bidding for commissions, and can use the simple rules framework to drive their own internal thinking about how to provide better access to care.

Thirdly, clinical and managerial leaders, along with frontline staff, should take a fresh look at access through the patients’ eyes, using the simple rules to focus observation. Mirroring the process demonstrated by the scenarios in boxes 2 and 3, clinicians and staff should carry out walk-throughs, audits, and videotape reviews of patients’ experiences and compare these with both sets of proposed rules. This process could lead naturally to approaches such as experience based design and help to set goals for improvements based on the new rules.9 10 In their roles as advocates for patients, frontline clinicians and staff can seek support for innovation, based on new rules, from their organisation. Practical guidance on how to apply the approach described in this paper can be found in Thinking Differently.22


Cite this as: BMJ 2008;337:a2321


  • Expert panel—Professor Sir Don Berwick, CEO, Institute of Healthcare Improvement (secondary care); Sir John Oldham, general practitioner and Former Chair of the Improvement Partnership (primary care); Professor Helen Bevan, Director of Service Transformation, NHS Institute for Innovation and Improvement (service transformation); Angela Coulter, Chief Executive, Picker Institute (patients); Julie Dent, former Chief Executive, South West London Strategic Health Authority (health community); David Fillingham, Chief Executive Bolton Hospital Trust (secondary care); Professor Chris Ham, Professor of Health Policy and Management, Health Services Management Centre, Birmingham University (health policy); Elizabeth Manero, Executive Officer, Health Link (patients); Dr Geoff Roberts, general practitioner and Clinical Champion for Service Improvement, Surrey and Sussex Strategic Health Authority (primary care); Dr Kate Silvester, Clinical Systems Engineering Coach (healthcare systems).

  • Contributors and sources: HR is a consultant urologist with a long series of award winning local service improvement programmes. He has had leading roles in NHS Modernisation Agency programmes during the past 8 years, and is a Senior Associate of the NHS Institute. He leads on development of clinical systems improvement methods, has studied interventions to reduce hospital mortality, and is leading a programme to transform quality and safety in operating theatres. LM is a critical care nurse with over 10 years’ experience in leading improvement and innovation and a doctorate in leadership for innovation. She co-authored Thinking Differently, a book of tools and techniques to help transform health services. PP, another co-author of the book, is a US-based consultant on innovation and complexity in organisations who has worked extensively with the NHS over 17 years. He serves as Chair of Innovation at the Virginia Mason Medical Center in Seattle, and is the director of the Academy for Large-Scale Change, a UK collaborative of senior leaders responsible for regional goals emerging out of Lord Darzi’s Next Stage Review. Each author facilitated workshops to unearth the rules. HR analysed the outputs and built the framework. All were involved in developing a scenario to illustrate how the rules work in practice. PP wrote the Ginny Jones story with advice from a consultant dermatologist. All authors contributed to the text of the final article. HR is the guarantor.

  • Competing interests: PP is a consultant who advises health care organisations on improvement and innovation. He derives fees from consulting.

  • Provenance and peer review: Not commissioned; externally peer reviewed.


View Abstract

Log in

Log in through your institution


* For online subscription