Apply for a maternity exemption certificate beta assessment

The report from the beta assessment for NHS BSA's apply for a maternity exemption certificate service on 12 April 2018.

From: Government Digital Service
Assessment date: 12 April 2018
Stage: Beta
Result: Not Met
Service provider: NHS BSA

To meet the Standard the service should:

  • Look into scalability of running and supporting of the service
  • Meet the accessibility standards
  • Eliminate citizen-facing downtime associated with deployments

About the service

Description

The service provides pregnant women and new mothers entitlement to free NHS Prescriptions throughout pregnancy and until the baby is 12 months old. The aim of the service is to help the mother remain healthy during the pregnancy and early motherhood.

Service users

The users of this service are pregnant women, new mothers, and healthcare professionals that help the mother to apply, including midwives and GP’s. The service will be used by approximately 460,000 users each year in England.

Detail

The Maternity Exemption Certificate service will be used to provide an exemption certificate to new and expectant mothers for prescription costs. The users of the service will be nationwide and from various healthcare professions, it will also potentially be used by the new and expectant mothers. The current method of obtaining an exemption is through a paper form that the healthcare professionals have access, and must be filled out by the healthcare professional and the mother. There are currently no plans to discontinue the paper channel.

The current design of the service involves the healthcare professional filling out the majority of the form and then the mother being sent a link to complete it. There is a new journey that is currently being tested that removes the mother from the journe. The panel could not see the user need for the mother to be involved in the journey, other than that the outdated policy requires it. The panel recommends that the new simplified journey, removing the mother’s confirmation journey and significantly improving the service for midwives, mothers and NHSBSA is further developed.

The panels main concern was that the current plans for running and supporting the service are not scalable. Account creation and maintenance is a manual process carried out by the team. Due to the amount of potential users it will quickly become unmanageable to manually deal with these requests.

User needs

The team has done lots of usability testing and contextual research to learn about the different people involved in the service. It’s good to see that the whole team has been involved in the research, as well as the in the analysis of the findings.

It’s great to hear the team has been speaking to people with lower digital skills and access needs. The team needs to continue engaging with the set of users and test any support model with the. The service needs to meet the accessibility standard for government services before they go into beta.

The team has done lots of work on how the users get their exemption. During the beta, they should also explore how the exemption is being used at the pharmacies and dentists. For example, the team has identified that it’s not necessary for the user to evidence their exemption when they get a free prescription. This is not clear in the user journey. Does this hinder users from getting their entitlement?

The team has been carrying out research and usability testing with midwives and other health professionals. In beta, the team should continue the work especially with some other health professionals that might be exposed to the service.

Team

The team is using an agile methodology to deliver this service. The panel was pleased with their description of the complete lifecycle of a research insight. They are using Jira to track their stories and show transparent priorities.

The team appears to be a good size and mixture of disciplines. The team do not have a dedicated content designer, interaction designer or service designer, instead those roles are shared across other teams within NHS. The team indicated that the amount of time they received from these disciplines was flexible and responsive to their needs. The panel was slightly concerned that the team didn’t have a specific person from the disciplines, instead whomever was available would be tasked with helping the team when required. The panel felt that the team would have benefited from having more access to a specific content designer, interaction designer and service designer.

The amount of senior engagement has clearly been thought out and planned by the team and wider NHS colleagues. The team is utilising pre-existing comms plans to ensure consistency and breadth of engagement.

The panel was pleased with the amount of engagement with policy stakeholders and the teams vision for how they could help shape and influence policy. The team acknowledges that engaging with their policy colleagues is not always easy but they are building up good relationships. These relationships should help them to make the service easier for the users by changing the policy to potentially not require the mothers input.

Technology

The team has constructed a modern Spring Boot frontend in front of an older stack managed by Capita, consisting of Websphere application server linked to an Oracle database. The team has been at the forefront of change within the organisation - as evidenced by the use of public cloud hosting. All tech is actively maintained, and the team has adopted good Dev Ops practices.

The panel was pleased to hear that the organisation is looking at replacing the older infrastructure but was unsure how much progress had been made on this since the alpha assessment.

Deployments within the Capita infrastructure cause regular downtime for end users, and the team have reduced the impact of this by scheduling deployments early in the morning.

The service has been designed in a way that does not replay sensitive information that the healthcare professional (HCP) has entered to the applicant. The service requires the applicant to click on a link in an email to complete the application. Although this email follows the Service Manual guidance on protecting users, it still presents a phishing risk. The new proposed flow would eliminate the email and associated risk.

The team has implemented a username and password authentication system for HCPs. The team explained that support for forgotten passwords, and vetting of registrations (currently via other channels as self registration is not implemented) is carried out by the service team. This system will not scale to thousands of users in public beta, and the additional password is unlikely to meet any non repudiation needs, as the team’s research has shown that HCPs routinely share passwords for other tasks.

The team acknowledged that it has released very little open source code during alpha and private beta, citing competing priorities as a reason this had not happened.

Design

The team showed a new journey where they had removed the need for the mother to make a declaration. This journey means the application can be completed by the midwife or health professional without extra input from the mother, speeding up the application and removing a major cause of drop outs. The new journey is being tested for a small portion of the private beta users and this has proved to be a success with a 100% completion rate. The service team is working with the policy team within NHSBSA to get approval to remove this step. The panel strongly recommend that this new journey is rolled out before proceeding to public beta as it is demonstrably a better experience for mothers and midwives and will reduce service failure demand and save time and effort for NHSBSA too.

The panel recommend the journey from the NHSBSA site and how midwives would find the service is explored more, as there are untested assumptions about this. Questions to consider include: where would the service start page live once in public beta? How would midwives and other health care professionals find the service?

The service currently uses the NHS SmartCard authentication service alongside a custom user account set up. The SmartCard service is being made obsolete in June 2018. The panel recommends that the team speaks to other teams within NHS Digital to learn how they are dealing with authentication and if there are alternatives. Creating a new authentication system will introduce new problems and security issues (eg the sharing of passwords within practices), and currently the account credentials are administered manually by the service team, which is not scalable or maintainable.

The service isn’t currently consistent with other NHS digital services. The service uses out of date design patterns for form elements, because the team found that their users preferred the older versions. It is recommended the latest design patterns should be used for consistency and to benefit from the learnings and improvements from across the community. Using out of date patterns increases the risk of missing out on usability and accessibility improvements.

The team should liaise with the NHS design community in NHS Digital to share their feedback and see how other teams across the NHS deal with similar issues.

The service uses a single date field for date entry. The team explained this is how midwives are used to entering dates and as they do this multiple times a day, across multiple services, using this format makes it easier for midwives to complete the form.

The team have tested the service with some users with different access needs, and have been in contact with DAC for accessibility advice throughout the development of the service. An accessibility audit from DAC is booked for 19 April and the panel is confident the team would be able to make any improvements and changes to the service quickly.

Analytics

The service team is measuring the 4 mandatory Key Performance Indicators (KPIs). A Performance Platform dashboard already exists, with data mainly from the legacy paper service, but hasn’t been updated since March 2017 although the team has offered to supply new data. Since then the digital take-up has increased from 0.2% to 1% during the private beta period, with 2,800 transactions. Publishing user satisfaction and completion rate on the Performance Platform is no longer mandatory.

The team is using Google Analytics, and some team members have had Google Analytics training. However, the team’s main focus is on data reported from the service database, including daily transactions and completion rates, and the days of the week and times of day that the service is used.

The team doesn’t have a dedicated performance analyst, but has access to a shared data analytics team. The service owner gives the team’s requirements to the data team. The data team will be doing some analysis of data from the private beta to tell the service team ‘what normal looks like’. They should also consider ‘what good looks like’, to establish benchmarks and targets for each metric and make a plan for measuring improvements.

The panel would have liked to see more emphasis on actionable insights, with the team using additional metrics and tracking to identify potential pain points within pages (even when users are successfully completing the service), to continually inform and measure iterations to the service.

Recommendations

To pass the [next assessment / reassessment], the service team must:

  • Roll out the newer simplified journey, removing the mother’s confirmation journey and significantly improving the service for midwives, mothers and NHSBSA
  • Eliminate citizen-facing downtime associated with deployments - could be met by adopting the new HCP-only flow or by introducing queuing between frontend and legacy infrastructure
  • Clarify the thinking and plan for HCP authentication. Depending on the level of confidence needed regarding the identity of the HCP, the team could explore:

  • integrating with a shared service for HCP identity and access management
  • verifying the user has access to an NHS email address
  • recording the claimed identity of the HCP (say a staff number) against the application for audit and monitoring

It is not sustainable for this service team to manually validate access requests and administer passwords for thousands of HCPs

  • Make the code for the service available under an appropriate open source licence. Adopt a process to open code regularly as it is developed to make this easier in future
  • Meet the accessibility standard for government services

The service team should also:

  • follow the recommendations in the content review
  • review the declaration content and make it simpler for users
  • liaise with the NHS design community in NHS Digital
  • work with the data analytics team to define hypotheses, how to measure success, and actionable metrics and targets, ideally by developing a performance measurement framework
  • contact the Performance Platform team (Cliff Sheppard - clifford.sheppard@digital.cabinet-office.gov.uk) to discuss uploading the past year’s performance data to bring the dashboard up to date, and consider whether the data can be uploaded automatically

Next Steps

In order for the service to continue to the next phase of development it must meet the Standard. The service must be re-assessed against the criteria not met at this assessment.

Please contact the Service Assessment team at least 4 weeks before the date you’d like to hold a reassessment.

Get advice and guidance

The team can get advice and guidance on the next stage of development by:

Digital Service Standard points

Point Description Result
1 Understanding user needs Not met
2 Improving the service based on user research and usability testing Met
3 Having a sustainable, multidisciplinary team in place Not Met
4 Building using agile, iterative and user-centred methods Met
5 Iterating and improving the service on a frequent basis Not Met
6 Evaluating tools, systems, and ways of procuring them Met
7 Managing data, security level, legal responsibilities, privacy issues and risks Not Met
8 Making code available as open source Not Met
9 Using open standards and common government platforms Met
10 Testing the end-to-end service, and browser and device testing Met
11 Planning for the service being taken temporarily offline Met
12 Creating a simple and intuitive service Met
13 Ensuring consistency with the design and style of GOV.UK Not Met
14 Encouraging digital take-up Met
15 Using analytics tools to collect and act on performance data Not Met
16 Defining KPIs and establishing performance benchmarks Not Met
17 Reporting performance data on the Performance Platform Met
18 Testing the service with the minister responsible for it Met
Published 6 August 2018