5 July 1948: A chance and a challenge

Earlier this year I set out to understand more about the history of the National Health Service. As well as reading some books recommended by colleagues, I’ve picked up a few original 1948 documents from online auctions. Some archaic language aside, they’re as fresh and relevant today as they were 70 years ago.

Exhibit 1: a variant of the wonderfully clear and concise leaflet sent to every household to explain the new service. The version I have was for service men and women, a reminder of the NHS’s roots in, and proximity to, the horrors and the heroic national collaboration of the Second World War.

The New NATIONAL HEALTH SERVICE
‘The New NATIONAL HEALTH SERVICE’ leaflet, 1948

As a value proposition, the introduction to this leaflet is hard to beat:

It will provide you with all medical, dental, and nursing care. Everyone — rich or poor man, woman or child — can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not a “charity”. You are all paying for it, mainly as taxpayers, and it will relieve your money worries in time of illness.

See the radical ideas packed into those 6 short sentences?
  • Comprehensive coverage – medical, dental and nursing
  • For everyone – rich and poor alike
  • Coverage of women and children equally with men (pre-World War II, many men were in work-based insurance schemes, but their wives and children had no such coverage)
  • Emphatically not a “charity”, but rather a collective endeavour by us all
  • It will relieve your money worries – because the stress of illness can only be compounded by financial hardship.

Every recipient of the leaflet also had a thing to do: “Choose Your Doctor Now”. Despite the scale of this national undertaking, the NHS took flight on the wings of millions of individual choices – people registering themselves and their loved ones with a family doctor. (Whether those GPs would take part at all was a close-run thing demanding give and take from Nye Bevan on one side and the GPs’ leaders on the other.)

Exhibit 2: fast forward a few months to this booklet, published by the Ministry of Health (loving that logo) soon after the NHS’s creation.

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A thicker, more reflective read than the first leaflet, this one was produced not long after the foundation, when most people had chosen a doctor, but the new system was just finding its feet. The first of many attempts to show who does what…

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Compare with this 2017 version from the King’s Fund…

The final, and most forward-looking, chapter of the second booklet is my favourite.

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6. BUILDING THE NEW SERVICE

THIS BOOKLET has tried to explain the reasons for the new deal in medical care, and the organisation created for it by the Act. It has described what the medical services look like in the beginning, soon after the Act is in force. What will they look like in ten years’ time? The Act is only the means of getting the new deal started. In what direction will the new partnership of the professions and the ‘consumers’ work to carry out their purpose of meeting the medical needs of the people adequately, everywhere?

See how the new partnership comes with scare quotes around the word ‘consumers’? Perhaps the authors hoped we’d find a better noun some time in the next decades. We’re still working on that.

The “six main aims” bear repeating – all having been reprised many times in the last 70 years…

(1) Up-to-date material resources. A large programme is needed as soon as it becomes practicable, for rebuilding and re-equipping hospitals and clinics and for constructing health centres.

(2) Adequate human resources. More health workers of most kinds will have to be trained as soon as possible.

(3) Better distribution of resources. The aim must be to bring more of the services to the places where the patient can conveniently use them.

(4) Greater team work in serving the patient. This is necessary among family doctors, within the hospital service, and between all the services, to avoid the departmentalising of medicine which prevents doctors from seeing the patient as a ‘whole person’ rather than as a ‘case’.

(5) Encouragement of variety and experiment. Medical needs must be adequately met everywhere, but it would be wrong for them to be  met everywhere in the same way. Medicine thrives on experiment and comparison of different ways of doing things; uniformity of method or belief is its enemy.

(6) Encouragement of a preventive and ‘positive’ outlook on health. All agree that the nation will not be using its doctors to the best advantage so long as they are confined so much to healing and have so little time for preventing illness.

In places the language of this booklet is breathtakingly modern. I had to do a Google Books search to confirm that the phrase “whole person” was indeed contemporaneous. Also note…

  • The emphasis on adequacy as an ambitious but attainable goal
  • The need to bring services closer to where people are
  • Team work across departments and parts of the service
  • My favourite: variety and experiment! “uniformity of method or belief is its enemy.”
  • The first of many pleas to prioritise wellbeing and prevention of illness

There’s a sober assessment of the nascent service’s chances. Transformation takes time, costs money and is inherently uncertain…

In the hospital and specialist services the pursuit of these aims will take time. There are still too many awkward and out-of-date buildings; even the existing accommodation cannot be fully used for want of nurses and domestic workers. There are too few of many kinds of specialists, and the few there are are not always well distributed in different parts of the country. The work of the specialist has to be carried beyond the hospital doors more than in the past.

Nevertheless, the Service must be run with proper regard for economy, and capital expenditure has to be kept down to a minimum. Only the most urgent schemes for the extension or repair of hospitals can be permitted. Nor is the building of comprehensive health centres possible on any scale while so great a part of our building resources has to be locked up in urgently needed houses, factories and schools. More study is also needed of the kinds of centres most worth trying out before any large-scale experiments are launched. The building and testing of health centres in action, in different forms and circumstances, in large towns and small, in suburbs and country areas, is a task for the next few years. During that time a great many, perhaps most, family doctors will continue to practise outside health centres, though various looser forms of ‘grouped’ practice and other means of improving the efficiency of the family doctor without comprehensive health centres may prove valuable especially in country districts.

For the time being the main thing is to get the Service into good running order and to keep on improving its efficiency. All big social changes start with a certain amount of uncertainty, until people get used to the new way of doing things; and this Service cannot be comprehensive in the fullest sense until the country is farther along the road to prosperity and a rising standard of life.

Implicit trust in the public as active participants, on whose wise decisions success depended…

The public has still to learn how to use the new facilities properly and economically; and those who are actually running the Service have to get used to new conditions and changing needs. But if the various professions really join forces with the laymen in the organisation described in this booklet, they can carry out a progressive new deal in medical care which will redound to the benefit of all.

A look back, as well as forwards…

The National Health Service represents the completion of the work which was started just over a hundred years ago with the first Public Health Act. Then the emphasis was on environmental conditions — pure water and proper sewerage.

Finally a chance and challenge that stands to this day…

Now the National Health Service brings together the personal services. It offers a chance — and a challenge — to build the most efficient health service in the world, and one which as the years go by will add steadily to the nation’s fitness, happiness and working capacity.

Both documents were subject to Crown Copyright for 50 years, so are now in the public domain. I have scanned and shared them on Wikimedia Commons:

Bonus feature: Halas & Batchelor’s lovely 1948 animation for the Central Office of Information…

Your very good health!

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“Look after the water” – reflections 1 year into my work at NHS Digital

Other people’s jobs are endlessly fascinating. At a birthday celebration a couple of years ago I got talking to Johnny, a family friend who works as an aquarium curator. He told me a surprising thing about his work: how little of his time he spends actually looking after the fish. Johnny’s job is to look after the water. “Look after the water,” he said, “and the fish will take care of themselves.”

So it is with design leadership. Our designers have different specialisms – service, interaction and graphic design. They’re embedded across a wide range of endeavours, both public and professional facing. They’re the ones who see users in research, and stakeholders in show and tells. My role is not to tell them how to design; it’s to create the safe and supported conditions in which they can do their best work, individually and collectively. When those conditions come together, it’s a wonderful thing.

This week it’s one year since I joined NHS Digital to lead the design team. I’ve been thinking about what has changed, and what we have yet to achieve. As ever, views all my own.

Growing a team

Our third whole design team event took place a couple of weeks ago in Leeds. We ran two rounds of rapid fire show and tells: 14 designers showing their work in the space of 90 minutes. I was massively impressed that every designer who presented was so good at telling their story, under time pressure, to a room of 35 people.

We’re lucky to have two excellent lead designers. Tero heads our growing service design practice, while Dean has taken on interaction and graphic design for the NHS website. Design-minded product managers Emma, Ian, and Sophie join us in our fortnightly design leadership meetings. Stephen, who left a couple of months ago, was always insightful, knew his way around the organisation, and took on the unglamorous task of writing job descriptions. I miss our Friday morning coffees.

Hiring for designers in both London and Leeds has been a long journey but rewarding in the end. Over the past few months, it has been great to see the new seniors settling in. I believe we now have talent at every level, and a good foundation for design leadership here in the future. If my bike went under a bus on Chapeltown Road tomorrow, weekly design huddles would still happen in Leeds and London. I count that as a win. Having designers who talk to and trust each other is the foundation of a coherent experience for our users. The designers and I are rewarded on the same pay scales as nurses, doctors, and other NHS professionals. That’s a sobering reminder of the value each new recruit to the team is expected to add.

A year of recruitment in numbers:

  • Just over 50% of the design team are now newer than me to NHS Digital
  • Of the permanent staff, 11 are still here from the team when I arrived, 8 are new recruits, and 3 have left
  • Among contractors, it’s 1 still here, 7 new, and 3 left
  • On top of that are a dozen or so supplier staff with whom we work closely as members of our extended team
  • Permanent team, contractors and supplier staff alike, 100% of them want to do their best for users and the health service.

Designers work best as part of multi-disciplinary teams. After a year here, I’ve had the privilege to see a few of those teams go through the delivery cycle from discovery, through alphas and on to release private and public beta versions. It hasn’t always been straightforward. Some teams have got stuck. Some things have stopped when we realised they would not achieve the outcomes we hoped for. But it does feel that teams are getting slicker at this – learning about user needs, and learning how to work together as true multidisciplinary teams. I’m fortunate to be part of a senior leadership team with brilliant product, delivery, technology and content leaders too.

As a design team, we have access to two larger communities of practice. NHS Digital’s Digital Service Delivery profession includes design along with user research, product management, delivery management and content design. We’re also part of the amazing cross-government user-centred design community, giving us access to Government Digital Service (GDS) training and community events. I especially appreciate my meetings with Lou Downe and the other government heads of design.

Here are some things I’ve learned…

Power is a big theme in health and care.

My focus has been with teams designing and delivering for patients, carers, and families – users who don’t work for the NHS or social care. There’s good evidence that people in control of their own health and care have better health outcomes. But I can see from our research how people’s power is diminished – by illness or disability, by social circumstances, and (though we don’t mean to disempower) by us, in the way we design and deliver health and care services.

Digital information and service have the potential to make people more powerful again. This can only happen when people can get them, trust them, understand them, decide with them, and act on them. For people to take power in the NHS, we need to work across the whole system, a partnership of patients, families, professionals, and service providers.

Sometimes we need to diverge before we can converge.

A healthy tension between divergent and convergent working should be part and parcel of any design approach.

Soon after I arrived a year ago, I worried that, in some areas, we were trying to converge prematurely on solutions that had not been tested against a wide enough range of user needs and contexts of use. To reach the required quality, we had to go through a phase of divergence in which teams went off to solve their own problems, while sharing their work and looking out for common patterns. (Patterns, by the way, are never designed; they can only emerge when teams are empowered to work independently, but transparently.)

Now, we’re back to a phase of convergence around design for the NHS website, led by teams explicitly tasked with redesign and standards creation. I have greater confidence that we’re building on firmer foundations this time, because we’ve tried more things, and understood more user needs.

I’m a design system sceptic (but we’ll probably end up with a design system anyway).

Everyone seems to be talking about design systems right now. I caution that explicit efforts to create a system can easily tend towards design for its own sake, disconnected from validated user needs and contexts of use. I hope we can keep ours rooted in reality by rotating designers through the overall redesign and standards teams, in and out of squads working on specific health condition categories and services. Nothing should get into the design system without being researched with users in multiple need states and contexts.

Rather than all swarming on the same problems, we need to conserve our energy and focus. Like birds flying in formation, each team can take a turn to lead on a design challenge, before falling back to let others fly ahead for the next stage.

Critical optimism is the order of the day.

When I wrote my 6-month update, the always-perceptive Stefan Czerniawski noted:

There is a sweet spot in any job, or more generally in understanding any organisation, when you still retain a sense of surprise that anything could quite work that way, but have acquired an understanding of why it does, and of the local application of the general rule that all organisations are perfectly designed to get the results they get.

Since then I’ve tried to bottle that feeling. Healthcare certainly proves Dr Deming right: that the same system can at once be brilliant at some things and terrible at others. There can be world class care, medical and technological innovation side by side with the shocking failure waste that comes from poorly designed service. Being a permanent member of staff, I feel a responsibility to work with the grain of the system, while retaining a sense of urgency to make things better.

One of my objectives is to grow the whole organisation’s commitment to human-centred design. This definitely feels like a multi-year commitment, but I’m confident that we have director-and-above-level support for improving the quality, consistency and accessibility of digital services for NHS patients and professionals. Our head of profession Amanda has been the definition of an empowering manager. Our portfolio director Alan has an exceptionally user-centred vision for someone in a such high-profile delivery role.

Update on some things I committed to do at the 6-month point:

  • Develop my own capability – I am investigating leadership courses that might be right for me. Ideally, I’ll do something that brings me into contact with a more diverse range of health and care leaders, not just the ones focused on digital.
  • Reflect and plan – I started by block booking Friday afternoons as a meeting-free zone in my diary. Clearing emails and weekly reporting always swallowed them up. Now I’ve blocked out the whole day. I don’t always keep to it, but it’s a good reminder of the value of meeting-free time.
  • Listen better – There’s a bit almost at the end of David Marquet’s ‘Turn the Ship Around‘ video, in which he says you will fail repeatedly at giving control to your team, but get up and go again. That’s where I feel I am with my coaching practice right now. After some conversations, I come away kicking myself. When it goes right though, it’s so much more rewarding to hear a colleague solve their own problem than to hear myself offering my solution. Ultimately this is the only way that a design capability is going to scale.
  • Influence more – Lots more to do here. There are so many opportunities for improvement that our small team will never be able to address them all. By sharing standards and setting clear expectations of good practice, we can multiply our impact and give power to the many other people across the health and care system who want to make a difference with design.
  • Say no to more things – One of the adjustments in moving from a micro-business to a biggish organisation was appreciating that lots of things get done even if I don’t do them. Every week or so, I look through my to-do list for the things I really ought to delegate, and the things I’m just never going to do. Adding a “Not Going To Do” column in Trello has done wonders for my sense of productivity.
  • Say yes to more things – I’ve been lucky enough to be invited to some brilliant events and conversations. A recent highlight was working with Victoria Betton and Lenny Naar to deliver a hands-on user-centred design session at HIMSS e-Health week. In October, I’ll be speaking at Interact London, and the conference theme is “Intelligence in Design”. Fingers crossed I’ll have something intelligent to say.

Weeknote: 14 to 18 May 2018

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.

Monday
Started the week with the Empower the Person portfolio Monday morning call.
Later in design team office hours there was a discussion about examples of well functioning multi-disciplinary teams. We have these working well in some parts of our organisation, and in others… less so. Lots of learning we can do from each other.
In the afternoon, I spent some time preparing for the session at e-Health Week (see Wednesday).

Tuesday
A catch up with one of the designers who has been working on the connecting to chlamydia testing service beta and is now moving across to join the NHS website redesign team. While it’s good to have stability on teams, it’s also important that the redesign work is done with input from designers who have worked across a wide range of content and services.
Lunch with a colleague from NHS England. We chatted about how human-centred design matches up with the personalised care programmes that he looks after.
Back at Bridgewater Place, a short intro meeting with one of our product development directors. I’m trying to work out how best design can support each directorate in NHS Digital’s new organisation structure, and he gave me some useful context.
Fortnightly design leadership meeting. We confirmed the agenda for the team event (see Thursday), talked about on-boarding some new starters, and generally tidied up the actions in the “doing” column of our design leadership Trello board.

Wednesday
A packed day at HIMSS UK e-Health Week in London.
On arriving, I dialled into a quick phone call I had scheduled with Chris who leads the 111 Online programme. (Only after the call did we realise we were both dialling in from different places at the same venue.)
I watched a main theatre presentation by Juliet Bauer, NHS England’s Chief Digital Officer, and the Senior Responsible Owner (SRO) for Empower the Person portfolio. While I know what’s going on across the portfolio, it’s always good to hear Juliet tell the story of the work we’re doing. I tweeted a couple of quite of special interest to me and my team.

After that, I was onto another phone call, with colleagues pulling together our response to the GDS consultation on accessibility of public websites and apps. Sarah, one of our digital graduates did a great job of keeping us on track as we worked through the questions in the consultation.
The e-Health Week session I ran with Victoria Betton of m-Habitat Lenny Naar from the Helix Centre was intended to be a hands-on taster of some key human-centred design principles. We asked people to work in pairs, one of them as the “user” of a page on the NHS website with a particular scenario in mind (we picked paracetamol as an example). The other half of each pair was the researcher, watching what their user did, and noting down any points about the experience. Later in the session, we asked them to sketch their own potential solutions to improve the page. Always nice to get a mention in someone else’s weeknotes.
Also at e-Health Week, I saw a session by NHS Digital’s Eve Roodhouse, David Corbett and Phil Nixon, and finally met (on her very last working day here!) our wonderful Chief Nurse Anne Cooper.

Thursday
On the way into work I picked up on a sketchnote of a #OneTeamGov meetup by Sam Villis at GDS, and got into an interesting conversation about the power of duplication.

Sam reflected on that in her weeknote too.
The main thing of the day was our design team event – the third time we’d got all the designers together from across NHS Digital since I started here last June. This time we welcomed guests, Helen and Lindsay from the NHS Business Services Authority. Everyone enjoyed hearing their honest account of simplifying the complex world of help with health costs. We ran a couple of rounds of rapid fire show and tells – 14 designers showing their work in the space of 90 minutes. In the event feedback, this format divides opinion – everyone likes hearing about lots of different services, but some say the 5 minute time limit feels rushed. I was just massively impressed that every designer who presented was so good at telling their story to a room of 35 people under time pressure.
Over lunch, some of us discussed the work in progress on changes to our cookie consent as part of the GDPR implementation.
The team day also gets a mention in Andrew’s weeknote. Andrew’s weeknotes are always worth a read.

Friday
I spent a big chunk of the morning with the Citizen Identity programme, chewing over naming and language in the service. Then an afternoon catching up with emails and planning for the week ahead.

Weeknote: 7 to 11 May 2018

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.

Sunday

I wrote a blog post reflecting on the Leeds Digital Festival event I was part of a couple of weeks ago: https://blog.mattedgar.com/2018/05/13/electric-woks-or-eating-together-time-for-human-centred-designers-to-care-about-the-community/ No more electric woks!

Electric woks or eating together? Time for human-centred designers to care about the community

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:

  1. an explicit understanding of users, tasks and environments
  2. users involved throughout design and development
  3. design driven by user-centred evaluation
  4. a process that is iterative
  5. addressing the whole user experience
  6. 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.

Cartoon man on stretcher
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!”

In what direction will the new partnership of the professions and the 'consumers' work to carry out their purpose of meeting the medical needs of the people adequately, everywhere?
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:

  1. 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?
  2. 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 include everyone 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.

Weeknote: 30 April to 4 May 2018

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.

Monday

Started the week with the regular programme directors’ call for the Empower the Person portfolio.

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.

When we got home, this book was waiting for me: https://public.digital/book/ Highly recommended!

Anyone can use it: some NHS history links and reading

Notebook with sticker: 'The New National Health Service 5th July 1948'

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:

The New National Health Service leaflet page 1

The New National Health Service leaflet page 2

The New National Health Service leaflet page 3

The New National Health Service leaflet page 4

What else should I look at?