‘Inclusive design’ and ‘accessibility’ are often used interchangeably, but they are different things.
An accessible product or service isn’t necessarily inclusive. For example, an online page about skin symptoms might comply with the latest Web Content Accessibility Guidelines (WCAG) and therefore be judged ‘accessible’.
But, if the content on skin symptoms is mostly described in terms of how they appear on white skin, with very few examples of what skin problems and conditions look like on other skin tones, it will be excluding people with different skin tones.
The impact of this is very real: a parent assessing at home whether their child has something less troublesome such as chickenpox or a much more serious condition needing immediate clinical attention, such as meningitis, might not have the information they need.
This is obviously intrinsically linked with clinical risk and we therefore have a duty, when designing services for the NHS, to always design inclusively.
Our journey
In 2021, the service manual team developed an inclusion microsite for internal use that provided guidance on making user research, design and content more inclusive.
Last year, we did more discovery work, identifying current user needs surrounding inclusive design. We also investigated what support people might need to embed inclusive design into our culture.
The latest phase of this work is to sharpen up our definition of what we mean by inclusive design, specify what it means in practice, and start to develop principles of inclusive design into a framework for our teams at NHS England.
Our process
We began by forming a working group of internal users with experience of designing and delivering a wide range of products. The focus was on fostering a collaborative approach that allowed people to contribute and learn freely. We called it a “brave space”:
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what people said in the space, stayed in the space
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what people learned from the space, left the space
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if people did or said something wrong, like using the wrong term, someone showed us a better way without judgement
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there were a variety of ways to contribute, such as through the chat, raising a hand, calling out or sending an email after a session
We ran 16 sessions to co-design the definition, framework, maturity model and training requirements. The inclusive design principles were at the core of how the sessions were formulated and we encouraged people to participate in ways that they felt comfortable with.
Defining inclusive design
We co-developed the following definition of inclusive design in the NHS context:
”“Inclusive design is an approach to designing and delivering services that ensures everyone can access NHS services regardless of their background or life experience.”
We also explored what this meant in practice. Some key points coming out of our discussions were:
1. Accessible design is one outcome of an effective inclusive design process
As we stated at the start of this blog, inclusive design and accessibility are often used interchangeably, but they are not the same. Inclusive design is an approach, whereas accessibility is an outcome of the design and delivery of a product or service.
2. Exclusion can happen to anyone
Our abilities change throughout our life. We gain or lose abilities because of illness, injury, age or the limitations of the environment.
When a task exceeds our ability to perform, exclusion happens. A person’s capabilities and limitations are always a factor in how successfully they interact with a service or product. Sometimes exclusion is temporary or situational.
Because exclusion can happen to anyone, inclusive design changes the perspective of designing for people with specific needs, to including and learning from people with diverse viewpoints.
Mismatched interactions also arise when we create solutions with only one way to participate. Inclusive design encourages designing a variety of ways that allow people access and participation.
3. Intersectionality affects healthcare service access
Intersectionality is a concept for understanding how aspects of a person’s disadvantages and advantages combine to create different and multiple prejudices or privileges. People with two or more disadvantages have a significantly worse experience in healthcare services.
4. ‘Universal design’ can lead to exclusion
‘Universal design’ originates from architecture and industrial design. It aims to create one experience that can be accessed and used, to the greatest extent possible, by all people. It tends to create one-size-fits-all solutions and it designs for the ’average‘ person. The fallacy at the heart of this is that there is no ‘average person’ and, by avoiding edge cases in the name of efficiency and scale, we can exclude people.
”Designing for what universal design might designate as ‘edge cases’ will tend to make the service better for everyone.
In contrast, inclusive design starts with understanding who is excluded from accessing NHS services and how people are excluded from these services. It emphasises the process of learning from, and designing with, a range of people. A particular focus must be communities or groups that are seldom heard or typically excluded. Designing for what ‘universal design’ might designate as ‘edge cases’ will tend to make the service better for everyone.
Working toward a framework
We are currently sharing our draft inclusive design principles on an internal microsite at NHS England.
Our aim is to make our advice as relevant and practical as possible for people working in a range of roles in leadership, product and delivery, research, design and development. We currently have more than 50 specific precepts in different areas as well as case studies and practical resources (for example, templates to help teams write better briefs for inclusive research recruitment).
