I wrote last week about designing for coherence. There are probably flavours of this. One flavour is how the interface feels. An app that connects people to lots of organisations still needs to look, work, and read like one thing.

The flavour of coherence I’m most interested in is the gaps between steps in services and organisations and how we make those work better for NHS users and staff. This kind of coherence is an attribute of a system where the parts fit together well enough that people don’t have to bridge the gaps themselves. I’ve talked about this a lot recently and want to get clearer in my own mind about what that looks like in practice.

I also have a suspicion that ‘end‑to‑end’ is the wrong framing for healthcare. ‘End‑to‑end’ implies linearity to how things work and that one part of the journey has control over the whole.

In NHSE, the pragmatic approach is to recognise and work with the disjointed nature of the system. The work is to find the seams and try to bridge them. That means taking care over how people arrive at a service, and how they leave it for their next step.

Designing to be a better part of the network also means being honest about who it does and doesn’t work for. When services don’t join up, someone has to do the work of joining them. Sometimes it’s GP practice staff. Usually it’s the patient. Patients chase appointments, repeat their story, and carry information from one organisation to the next. People with time, confidence, and good English can absorb the work. People without those things are more likely to drop out.

Here’s a long, but not exhaustive, list of what I think we need to make happen as parts of a network.

Users:

  • know what their next step is before it starts
  • know who their next step is with
  • know why it’s necessary and what happens if it doesn’t happen
  • are expected at the next step
  • don’t have to repeat their information at each stage
  • get consistent communication
  • are told if there is a delay or change
  • are followed up with, if they don’t take their next step
  • can come back later, if they’re not ready
  • can say ‘no’ or ‘stop’
  • have the same named person to speak to across the whole journey (this might not be realistic or necessary for less serious needs)
  • are treated like human beings, with their own story, needs, and experiences

Staff:

  • know what happens next so they can tell users what to expect
  • have up‑to‑date information
  • don’t have to chase other organisations or re‑enter information to keep someone’s journey moving
  • see when someone doesn’t progress
  • can safely raise problems wherever they happen
  • have the tools and control they need

The system:

  • supports everyone, especially those with the least capacity
  • accounts for language and literacy
  • accounts for people with no fixed address or who move between areas
  • knows where someone has been in the journey, where they are now, and where they might go next
  • makes sure someone owns the gap, even when no single team owns the whole journey
  • aligns incentives, commissioning, contracts, and information governance to reward joining up

This is aspirational. Some of it happens already. NHSE is a part of the whole and whether this happens is mostly down to local systems. What is our role, and what can we do to help make it happen everywhere?

I think it starts with relationships. Services join up better when the people running them know each other, trust each other, and talk regularly. It also needs agreements between organisations about what data can be shared to better support patients. So we should build relationships between people first, and software later. Coherence is not a series of transactions. It’s relationships.