I started writing weeknotes soon after I joined NHS Digital as head of design in June 2017. I find it a good discipline for me to reflect on my week, and to make sure I’m making progress against my own and my team’s objectives. Because groups of colleagues congregate in different virtual places, I settled on posting them simultaneously to our #design channel on Slack and an internal “blog” on Sharepoint. As an experiment, I’m posting a lightly redacted version here too. Views: my own. Publication status: experimental.
Tuesday
Straight back from the bank holiday weekend into NHS.UK programme show and tell day. In addition to the team’s showing their work, Marc, our head of products, gave an update from the senior leadership team. We plan to make these a regular fixture at fortnightly show and tells in future.
I joined a presentation by Helen Petrie of York University, who specialises is research with users with access needs, including older people. It gave me lots to think about. Thanks to Rochelle, Tanja, and the other user researchers for making it happen.
Dean, the lead designer on the NHS website, shared the team’s stance on accessibility with our NHS Digital Ability Network, which supports staff with disabilities, long-term conditions and carers, and got some encouraging feedback.
I also had a call with Victoria from m-Habitat and Lenny from the Helix Centre about a session we’re doing together as part of HIMSS e-Health Week.
Wednesday
A day in London. I had a chat with Louise, the service designer on apps & wearables. I met a service designer working in a well-respected design agency, who was interested in how we work as an in-house team.
Thursday
A call with Amanda, our head of profession.
Then I headed over to the Government Digital Service event, Sprint 18, where I managed to persuade Andrew to sign my copy of the public.digital/book. My takeaways from the event:
Cross-government collaboration works. For example, to make their emergency travel documents service, Foreign Office reused appointment booking from Ministry of Justice, GOV.UK Pay from Government Digital Service, and photo upload from Home Office.
Making things simple is hard work (but worth it in the end). It took new legislation, a multidisciplinary team, with policy and digital, from two departments, co-located, to make it possible for you to ‘check your state pension’.
The Digital Service Standard is no more! It has been rename the Government Service Standard to reflect the fact that it’s not just digital, but a standard for the whole of government.
There’s lots we can do to raise awareness and build capability around accessibility: “Interest can’t be the only motivating factor, you need some goals and management support.” – James Buller, one of two access needs leads at the Home Office.
I missed the presentation of advances on the GOV.UK platform to head over to Parliament for an NHS Digital event on diversity inclusion. Nicola, who leads on Widening Digital Participation talked about her programme’s work with partners Good Things Foundation. There were also great talks by Stan, experts by experience lead at homelessness charity Pathway, and Jonny, of social enterprise charity Turning Point.
Friday
Catching up with emails, and following up on the process to bring a designer on board, having made them an offer some time ago. I followed up on the accessibility and inclusion work, including clarifying how we’re approaching the GDS consultation on accessibility of public websites and apps.
For the last couple of hours, I looked again at one of the job descriptions we’re putting through the Agenda for Change grading process. It’s a valuable exercise because it forces us to describe the work of a designer against a set of generic competencies that have to be broad enough to fit the massive range of job roles in the NHS. If we get it right, designers will get recognition for their key roles in:
Policy and Service Improvement – our job is to design new services, or substantially improve existing ones, on nationally important areas of health policy and performance.
Research and Development – we spend much of our time exploring and learning in the discovery, alpha and beta phases of service development.
Equality, Diversity and Rights – the designer is the primary advocate in the multidisciplinary team for the principles of inclusive design.
Mick Ward is sick of people trying to sell him electric woks. As chief officer leading transformation and innovation for social care in Leeds, he sees a never-ending procession of providers claiming to solve enduring human problems with expensive, complicated, isolated, digital solutions.
Mick believes we’d do better to start with people and their communities, with their strengths and how they can work together to make things better for themselves. Communities like Seacroft in east Leeds, where the LS14 Trust asked a simple question: “What would happen if we spent a whole year eating together as a community?”
“You can have the healthiest greens on your plate, but if you eat in isolation every day this might not always be good for your long-term wellbeing.” – LS14 Trust video
A couple of weeks ago I was privileged to be on a Leeds Digital Festival panel with Mick, Howard Bradley from the LS14 Trust, and Roz Davies from the Good Things Foundation. The event was organised by Victoria Betton from m-Habitat, who has also written up her impressions of the event.
On the agenda, I was there to be the “digital” voice in the conversation as a counterpoint to Mick and Howard’s advocacy of asset-based community development (ABCD). But I also accepted the slot on the panel to listen and learn, because I’ve long had a hunch that ABCD contains much that could improve my practice.
While we digital designers talk a good talk about focusing on people, I can’t help thinking our processes are still too often tilted in favour of electric wok solutions, and too rarely towards things like eating together.
In my contribution to the event, I offered what I hope was a critical description of the principles of a human-centred design process, as set out in the international standard ISO 9241-210:2010. I talked about the good things we always try to maintain:
an explicit understanding of users, tasks and environments
users involved throughout design and development
design driven by user-centred evaluation
a process that is iterative
addressing the whole user experience
multidisciplinary skills and perspectives
There need not be a gulf between human-centred design and ABCD, but often, by sins of omission, there is.
The problems start with the deficit-based way we often talk about “user needs.”
Inherently, a user need is a deficit, a thing a user lacks, a gap that we service providers claim to fill with our special expertise. Human nature makes it so easy for us to slip into electric wok thinking: this person is hungry; we make electric woks; what they need is an electric wok.
When the user protests that she never eats stir fry, many of our community double down on this deficit-thinking, by asserting that “people don’t know what they need.” The Henry Ford quote about a faster horse is trotted out, or something about how Apple don’t do user research (He never said it; they do.)
Human-centred design theory emphasises that we don’t take people’s stated desires at face value. We say no to that market research staple, the focus group. Instead, we uncover latent needs using ergonomic and ethnographic observations of actual behaviour (“Saturday, 1:27am: Participant orders takeaway chicken chow mein.”)
Rushed or done badly, such approaches render the research participant little more than a lab rat. The experimental subject’s only stake in the transaction is a shopping voucher to thank them for an hour of bemusement that they’ll never get back.
Empathy is essential in any human-centred design process. The trouble is, we often get it muddled up with sympathy.
When we see someone in pain, or with problems, or less fortunate than ourselves, our instinct is to help them. That’s a brilliant human thing. It’s mark of a civilised society that we have a safety net, no questions asked, to pick up a person when they’re knocked off their bike or floored by acute illness.
Still from ‘Your Very Good Health’ – Central Office of Information, 1948
Once the initial crisis has passed, however, sympathy must give way to a fuller understanding of the person and their capacity to recover. True empathy means feeling their hopes for the future, the things that make them resilient, knowing which activity they’ll enjoy the most to rebuild wasted muscles.
The factors that make someone strong are so personal and so varied that they are often forgotten in the focus on what’s commonly wrong. And in the name of equality, “not everyone has capacity” becomes a reason to ignore the assets of those who do. It’s then only a short step from fixing the problem to fixing the person, applying the faulty logic that if we are well, then making them more like us will make them well too. True empathy takes people as they are, not as we wish them to be.
It doesn’t have to be this way, but human-centred design has become, by default, individualistic.
There is a rich heritage of more social strains of service design and participatory design. In recent years, these have been drowned out by digital user experiences, where the context of use is invariably a person alone at a computer or on their personal mobile device.
Reacting against the phoney seance of the focus group, we prefer one-to-one usability sessions and depth interviews. To drive out ambiguity, we write user stories in the singular: “As a user, I want to… so that…”.
When we over-rely on these methods, we miss the plethora of relationships beyond the individual user and service provider. When we think about inclusion and accessibility, we fail even to ask users whether they consider it more “independent” to complete a task alone with assistance from a service provider, or by sharing it with a family member or friend.
Finally, as a questioner at the event pointed out, the language around this stuff has always been problematic.
We borrow the words of marketing “activation” as if people were machines waiting to be switched on. I work in a portfolio dedicated to “empowering people”, but who are we to give power in the first place? How about “stop disempowering people!”
Extract from 1948 booklet ‘The New National Health Service’
I take consolation from the fact that a 1948 leaflet on the new National Health Service places the word ‘consumers’ of healthcare in scare quotes, as if our founders knew the word was unsatisfactory, and that sooner of later someone would come along with a better term. 70 years later, we’re still working on that.
I ended my discussion by posing two related questions:
How might we move beyond purely transactional models of provider and consumer to more fluid configurations of actors, in which all contribute to and take from the service according to their needs, wants and abilities?
How might we (especially those of us charged with making digital services at national scale) recognise that service is co-created and co-produced in communities, and provide platforms for those communities to discover, express and meet their own needs?
We can stick to our principles of human-centred design, but we need to broaden their interpretation.
ABCD reminds us to consider user assets at least as much as user needs.
User research should includeeveryone as equals, helping them to beneficially articulate things they do know at some level, but have not yet consciously considered. Only then can they become active participants in the co-design of solutions that suit them.
Asset mapping is a common research activity in the ABCD world, but Mick from the council is very clear: the asset maps aren’t for him, they’re for the community, to realise what they already have. And when they’re made in a participatory way, the assets they surface are very different from the usual libraries and sports centres that turn up on maps made by the service providers.
I was recently challenged about user needs in a learning context, where people literally “don’t know what they don’t know”. Yet learners do know many other things that are highly relevant to the design of their learning, such as what they know already, how they will fit learning into their everyday lives, and what they hope to achieve with their new knowledge and skills.
The whole user experience is situated at least as much in places and communities as in individuals, devices and service providers.
Beyond the place-based work of community development, there are some promising developments in the digital world.
The always insightful Cassie Robinson at Doteveryone is thinking with Citizens Advice about collective action:
Collective action is a strand of work we’re committing more time to over the coming months at Doteveryone, discovering other opportunities and contexts where collective action can play a role in scrutiny, accountability and influencing change. As part of this work we are also looking to civil society organisations to take a role in empowering the public and their audiences to take collective action in directing the impacts of technology on our lives.
Projects by If’s new report with the Open Data Institute considers some of the many instances when organisations deal with data about multiple people:
Services that allow data portability need to consider social relationships to ensure they are respectful of people’s rights. It’s also important that services don’t make assumptions about how groups make decisions about moving data: instead, they need to allow people the time, space and awareness to work things out for themselves.
Users must be involved throughout design and development in more than one way:
as participants in user research specified by the Government Digital Service
as senior stakeholders such as patient leaders in some NHS organisations
as fully fledged members of a multidisciplinary team, for example by bringing experts by experience onto Care Quality Commission inspections.
While many organisations employ people in one of these modes, very few yet combine all three. This means false conflicts are set up. User researchers complain that consultations are conducted with “proxy users” instead of the actual people who will use a service. The most committed service users, with much to contribute, can be told their experience disqualifies them because “they know too much”. In truth, we need them all!
If we want fewer electric woks in our future, we’d better stay open to unexpected outcomes.
Howard described compellingly how the LS14 Trust works to “hold spaces” where people can explore and create at their own pace – “laptop in one hand, cup of tea in the other”. They start conversations on people’s own terms, asking “what do you want to change?”
As a question from Victoria highlighted, we must always be aware of power imbalances in these spaces. People will be inhibited from contributing fully if they feel they should say what the most powerful people in the room want to hear, or if, on the basis of their past experiences, they don’t believe their participation will really change anything.
And Mick shared a set of questions that ABCD practitioners use to check the impact of their interventions:
What will be enhanced?
What will be restored?
What will be replaced?
What might this mutate into?
A great set of questions to ask when designing almost anything.
I started writing weeknotes soon after I joined NHS Digital as head of design in June 2017. I find it a good discipline for me to reflect on my week, and to make sure I’m making progress against my own and my team’s objectives. Because groups of colleagues congregate in different virtual places, I settled on posting them simultaneously to our #design channel on Slack and an internal “blog” on Sharepoint. As an experiment, I’m posting a lightly redacted version here too. Views: my own. Publication status: experimental.
After that, I went over to NHS Digital HQ at Trevelyan Square for advice from an HR manager about my own professional development. I believe the NHS needs people-centred design leadership at director, executive board, and CEO levels, and I need to develop my own senior leadership skills if I am to be one of those future leaders. This might involve applying for one of the leadership development programmes that run across the NHS. I might also benefit from executive coaching and more senior mentorship.
1:30pm on Monday is the regular design profession office hours on Slack. I shared a draft agenda for our forthcoming design team event and encouraged people to sign up for show and tell slots.
In between time, sorting out tickets for Leeds GovJam (6-7 June). NHS Digital will be taking a block of 10 places which we plan to allocate to colleagues who would benefit from this awesome service design and design thinking experience.
Tuesday
I played a small part in helping the Widening Digital Participation Programme prepare for the launch of their Digital Inclusion Guide for Health and Social Care. It’s a great piece of work, full of useful advice and links, now published on our corporate website: https://digital.nhs.uk/about-nhs-digital/our-work/digital-inclusion
Another meeting with an HR manager – this time to get feedback on the new job descriptions we’re creating for designers. The goal is to have a complete set of job descriptions at a range of seniority levels. They’ll all be consistently graded using the same Agenda for Change bands as nurses, doctors, NHS managers and other professionals.
In the afternoon, it was the fortnightly design leadership meeting. We talked about the cross-government service design event that Tero is helping to organise. Also recruitment, on-boarding, accessibility, and design governance. Finally we discussed the growing number of requests for designers to help with small, short notice artwork or production jobs. Everyone wants to be helpful, but we need to make sure we have visibility of these, and be sure that they’re the best use of our designers’ much-in-demand skills.
After that, Dean, the lead designer on the NHS website, and I dialled into a briefing on the NHS.UK programme for our colleagues at the Department of Health and Social Care and the Government Digital Service (GDS).
Wednesday
I spent the morning and early afternoon at a network event for Health Education England’s technology enhanced learning programme, where I presented our user-centred design approach. I enjoyed hearing from online learning start-up founder, speaker, and general provocateur Donald Clark, and learning about some of HEE’s work improving the quality and consistency of online learning across health and social care.
Back at Bridgewater Place, I got a sneak preview of a new mobile-first header design before pop-up user testing later in the week.
At the end of the day, I went for a coffee with Paul from ODI Leeds, the brilliant Open Data Institute node of which NHS Digital is now a sponsor. I can’t wait to see what our teams can do together.
Thursday
I deputised for Amanda, our head of profession, at the monthly NHS Digital Heads of Profession Forum. At a time when our organisation’s operating model is changing, this group has an important role to play in maintaining professional standards and realising our goal of being a learning organisation.
A shorter than usual NHS.UK senior leadership team meeting, followed by the weekly Leeds designers’ huddle, a chance for any designer to show work in progress and get feedback from their peers. Then a catch up with Pete, the designer on e-Referrals.
Friday
Catching up with people and emails. I try to keep Fridays free to reflect and plan for the following week, but sometimes important things crop up that make me break that rule.
In the afternoon, a call with colleagues to discuss our organisation’s potential response to the GDS consultation on accessibility of public sector websites and apps. Teams here already take their accessibility obligations seriously, and the new EU directive will help to further sharpen the focus.
Saturday
Took my 12-year-old son to see the start of the Tour de Yorkshire stage at Richmond.
Service design in the public sector is, as Lou says, 10% innovation and 90% archaeology, and never more so than when working in a great national institution in its 70th year.
Realising I needed to learn more about the history of our National Health Service, I asked the Twitter crowd where to start. Here’s what people said:
Lorna highlighted the work of the NHS at 70team, to create a shared social history of the NHS
Dean recommended starting with the 1942 Beveridge Reportwhich set out, in the middle of the Second World War, a comprehensive new vision for post-war social welfare
This is part two of some personal reflections on my first six months at NHS Digital. Catch up on part one here.
The design team we need.
Many of our designers are highly motivated by the mission of the NHS. They must also be critical friends. Friends don’t let friends settle for second best when it comes to what’s possible with user-centred design. We need our new recruits to bring to the table diversity of background, empathy for all our different users, and a wide range of skills to conceive and realise a continuously improving service.
We’re still finding the balance between working embedded with programmes while being a unified team. In the next phase, a tactical approach to recruitment needs to give way to a strategic structure organised around user archetypes and needs states.
There are so many open goals for user-centred design in the NHS, and not enough players on the pitch to score them all. Partly we’ll grow the numbers by recruiting more people to our team. While recognising that some skills are hard to find right now, we don’t always need to fish in the same tiny pond as our job market competitors. We can also do more to grow our own talent, from entry level through to making great designers into future design leaders.
I hope very much that we are developing a team culture of consistency, fairness and respect. We need to develop and maintain parity of esteem between our three main design specialisms: service, interaction and graphic design. While they differ in the materials they work with, they all share a core user-centred practice.
The foundation of a successful design team is simple: designers talking to each other.
First, designers lead other designers to achieve more together than they could alone. The growing team becomes self-organising as they share their work, seek advice, and give constructive peer review. It’s a joy to see designers stepping up like this, and important to give them space and trust when they do so.
Next, design as a practice starts to lead the wider organisation to achieve better outcomes. This requires confidence, capability and visibility among the design team, and a keen awareness of what the organisation’s non-design leaders are trying to achieve. I feel fortunate that many here are open to new approaches. More often than we realise, we’re pushing at an open door.
Some things I will remind myself to do every week:
Today it’s six months since I started at NHS Digital. Along the way, I’ve written a bit about how we work on the NHS Digital Transformation Blog. For today though, I wanted to share some personal reflections here on my personal blog. I’ll do it in two parts, starting with the digital experience we deliver, and the platform for learning and delivery. Part two has more about building a team and design capability. These thoughts may not all reflect the opinions, strategies or positions of my employer — but I’m working on that :)
I’m still learning about the breadth of digital experiences we need to enable in health and care.
In every show and tell I’ve attended, every research session I’ve observed, there are unique nuggets of insight that show the sheer scale and diversity of the user needs we are here to meet. But there are some themes that come up time and again.
Simpler, clearer, kinder. Even more than other public services, we owe it to our users to make everything simple and clear. Many patients are the unrivaled experts in their own histories and conditions, but clinicians hold the medical knowledge and experience. Service insiders see and do procedures many time a week that their patients may encounter only once a lifetime. People who can perfectly well navigate complex services when in the best of health come to us at a low ebb. Fear and urgency act as temporary cognitive impairments. We need to make things simple, but never simplistic. We need to find ways to support people along journeys that seem straightforward in the abstract, but have many twists and turns as individual lived experiences. Often the best thing digital service can do is to get out of the way.
Sometimes an answer is not the answer. There’s evidence that people with knowledge, skills and confidence in managing their own health and care have better health outcomes across many conditions. This “patient activation” means moving beyond a learning paradigm of knowledge transmission – to a coaching-led approach, in which users construct answers that make sense in their own lives, and make up their own minds, with appropriate support. Before we get carried away about artificial intelligence, let’s build on our users’ human intelligence.
Design for humans, together and alone. Even when delivered by a cherished nationwide institution, healthcare is always personal. This plays well to our practices as user-centred designers. Throughout design and delivery, we aim to involve the individual beneficiary of the service. In health, however, that user is rarely one person, alone, accessing the health service for themselves. We must broaden our perspectives to perform not just person-centred, but family-centred, locality-centred, even population-centred design. The further down that list we venture, the more we must borrow tools and techniques from other disciplines, from policy and the social sciences.
Own the line of visibility. The line of visibility on a service blueprint separates the stuff that happens “frontstage” – seen by the service user – from “backstage” activities that may be just as vital to the delivery of the service but need not be witnessed by its beneficiary. Sometimes the curtain is there for a reason. To glimpse behind it would be a needless distraction. Sadly, many NHS communications are still filled with backstage jargon. That only baffles and disempowers the public. On the other hand, information may be withheld because it is wrongly assumed to be of no value to other parties. Letting people see behind the scenes can put them in control, and make them creative participants in the improvement of our service.
I can see the makings here of a platform for innovation across health and care.
One of the most rewarding days so far was the one I spent with colleagues and collaborators thinking about design principles for health and care.
This system is complex, in a Cynefin sense. We cannot control and understand it all, but we can probe and learn what patterns of digital intervention work in different contexts. The people who succeed here do so by working with, not against, the networked nature of the NHS. If we can grow enough of those people, and make it easy for them to run safe experiments, then we’ll have a platform for lasting system change.
A learning platform. We start by understanding the intent behind the things we’re trying to make. We prioritise and make decisions based on the best evidence available. Working at pace, we make prototypes and test to see if they have the impacts we intend. Sometimes it takes time for these impacts to be felt at the point of need. But when felt, they’ll be stronger, and scale faster, because of the care and attention put into learning in tandem with delivery.
Emergent patterns and standards. When I see a piece of work from one of our teams, I often ask myself, ‘are we trying enough different ways of doing this?’ We need to diverge before we converge on proven solutions. Only patterns that have proved themselves should make it into our pattern library and service manual.
Everybody wants to help. It’s been humbling how many people have been in touch wanting to help with design for digital in the health service. Thanks to all of you, and apologies to those I haven’t yet managed to meet with. We have lots to do here, and will need help in many different forms.
