1. Something changed

On 5 July 2018, the National Health Service turned 70. I was exactly 13 months into my own time with the service.

According to my calendar, on that day I: met Lisa from GDS, attended the NHS website fortnightly show and tell, chaired the design governance board, took my cat to the vet, and heard a playback of user research on clinicians’ attitudes to the website.

The morning after the 70th anniversary day, I tweeted 3 truths as I saw them about innovation in the NHS. They’re in tension, but not contradictory…

The service as a whole needs more money. Innovation must be led by the people who deliver the service, the ones who know where real opportunities lie. They need some slack in the system to learn new skills and try new approaches.

The opportunities afforded by new technologies are massive and awesome. NHS people need to get smarter at spotting what’s genuinely transformational. Otherwise we’ll just squander any extra money on fads and snake oil.

The system is still rife with failure waste, much of it caused by poorly designed IT. The fixes for this are well known, systematic, and start with better understanding of human behaviours, not with force-fitting unproven new technologies.

The NHS belongs to the people. Those of us on the inside have a duty to be honest and truthful in carrying out our jobs. (That’s in the NHS Constitution.)

We also depend on critical friends outside NHS organisations. For our friends to contribute, we must set high standards of openness, assume criticisms are well-intentioned, and amplify the voices of people who don’t have privileged insider status.

At that point, we were in full on “strategy is delivery” mode, heading towards the Health and Care Innovation Expo, a massive annual conference-cum-trade-show of all things health and care. When teams are continuously delivering value to users, synthetic milestones like this ought not to matter much, but in our world they do, and even more so this year, on which more later.

There were pre-launch nerves, but we made it to the Expo in the first week of September with a visibly different, mobile-first, more accessible and usable NHS website — and a new name to top it off. No more “NHS Choices”. There’s still much more about the website that we can improve, but that was an important turning point for everyone on the team.

In another building half a mile across Leeds, the equally talented team on the NHS app were working independently to their own private beta timelines. Dean, our lead designer, became the shuttle diplomat making sure that app and website would look and feel part of the same family.

Also in time for Expo, we released a beta version of a new NHS digital service manual, including design principles created in collaboration with some of our partners and other NHS organisations. The design principles are in beta too, and we welcome your feedback.

Expo 2018 was a 2-day event in Manchester. I didn’t make it in person to the first day, but did catch some of the highlights streamed by our communications team colleagues.

I popped across the Pennines on day 2, mainly to support Rochelle and Tero, who were working with Simon and Kassandra from Public Health England on a session about user-centred design – which all four of them ran brilliantly.

At 3:30pm, the exhibition stands emptied out as everyone crammed into the auditorium for the main event, the Secretary of State’s keynote speech. For a flavour, try this sample quote:

“Mandated standards are just the start. Too often people with too little technical understanding are buying IT from suppliers who want to capture the buyer so they can’t ever go elsewhere. Suppliers’ interests are too often not aligned with the NHS’s interests, and the contracts badly managed. This supplier capture is common in IT, but it is not inevitable. So we are seriously going to increase the in-house capacity to understand the technology, to procure the right things, to manage them better, to split up big contracts into smaller pieces, to ensure an agile, iterative approach focussed on the question: what is the user need?”

Two days later I was back in Manchester, this time in a t-shirt not a suit, for UK Healthcamp. It was my first Healthcamp. What a lovely group of people to spend a Saturday with any time. In the light of Matt Hancock’s speech, and with his tech advisor Hadley in the room, it felt as if this band of health tech radicals’ moment might have arrived.

I learned loads at Healthcamp, put faces to names I’d long followed from afar, and posed a question of my own to a windowless basement room full of thoughtful healthcampers: “What do people need to be able to trust a digital health service?” It’s a question I’d been thinking about a lot, because the fifth of our design principles is “Design for trust”.

So this 6-month note breaks almost exactly into two distinct halves: before and after 6 September.

In the weeks that followed, while the NHS website team enjoyed a well-deserved boost in confidence and credibility, I was privileged to contribute in a few tiny ways to a set of vision and planning documents that make the new direction clear.

On October 17, the Department of Health and Social Care published the vision for digital, data and technology in health and care, alongside NHS Digital’s draft standards framework. The latter also sets out our intent around service design standards for health and care.

This work doesn’t always happen in the open, which is shame. We should constantly be asking “who is not in the room, but should be?” Nevertheless I’ve been hugely impressed by the commitment to user-centricity among the people tasked with making those plans, and by their openness to challenge and new ideas. As Ben Goldacre put it:

There’s a trolley, trundling through Whitehall and the NHS, with ‘Make NHS IT Better’ written on the side. If you throw your thoughts into that trolley, right now, they will join all the other ideas, problems and plans.

What purpose do these documents serve? Policy papers won’t fix the problem; people and delivery will. But I feel — really feel — that the last 3 months have made us all bolder. It has been lovely to see the emergence of a new coalition of people from across health and care rallying round the principles in the vision paper.

Among the people reacting, I see some archetypes. These are not a comprehensive taxonomy. I have been all of them myself at different times in my career.

• Some people have long worked for a focus on user needs, privacy and security, interoperability and openness, and for inclusion. They’ve done this in the face of legacy technology and commercial arrangements, complex organisational and delivery structures, and a risk-averse culture that failed to register any of those things as the real risks. I hope they’re not now too worn down to seize this opportunity.
• Some have focused on particular topics, such as clinical informatics, patient and public involvement, data geekery, privacy activism, agile procurement, or user-centred design. Often they’ve been stymied by the “dark matter” that arises from the other problems not visible inside their own paradigms. This vision demands a new, shared understanding between the different practices. None of us has all the answers.
• Then there are the shy reformers, secretly inspired by the progress of user-centred, agile methods elsewhere in the public sector. They’ve been tamping down their enthusiasm, reining in their ambition, in order to make progress in legacy organisations. After reading the tech vision, they shouldn’t have to do that any more.

I’m mindful that others are still reserving judgement.

• Some will look at the architectural principles in the vision and find a dozen reasons why their particular corner of the digital world is special. Telling them they’re wrong or stupid won’t help. We must show them respect, evidence, and examples, not just words.
• And many have been burned before. After years of mismatched understanding between users and suppliers of healthcare technology, why should they believe that this time is different? The burden is on us to prove it is.

Service design, as a people-centred, holistic, co-creating discipline, could have a big part to play in bringing these tribes together around a shared purpose of better care and improved health outcomes for everyone in England.

2. Freedom to act

In my 12-month report, I mentioned the influence of David Marquet’s ‘Turn the Ship Around’. His over-riding imperative is to give control to the people who know best: to “move the authority to where the information is”. In order to succeed at this, he says, there are two pre-conditions: clarity and competence:

… as control is divested, both technical competence and organisational clarity need to be strengthened.

So if, on 6 September, or maybe on 17 October, the NHS reached a moment of digital clarity, how are we building the competence to make it real in the profession group I look after, design?

Whenever I need a reality check, I remind myself that our entry level design assistant role is on the same NHS pay band as an A&E paramedic; our lead designers are on a level with consultant psychologists. To make sure there’s a good reason for that, we’ve been though the NHS Agenda for Change job evaluation scheme, which assesses the knowledge, responsibility, skills and effort needed to do each job.

Technical skills and familiarity with design methods are part of the picture. But we’ve also had to explain what designers do according to a controlled set of generic responsibilities. I found that a more useful exercise than I expected. Here are some highlights against the Agenda for Change responsibilities:

• Design is Research & Development – we discover needs. We make alphas and betas. Design is surely the silent third letter between R&D!
• Design is Policy and Service Improvement – we take responsibility for the design of a new service, or substantial improvement to an existing one. We can show how different hypotheses for policy change are linked (or not) to user needs
• Design is Quality – we champion key “non-functionals”, such as usability, accessibility, and desirability
• Design is Equality, Diversity and Rights – we’re advocates for the principles of inclusive design
• Design is Communication and Relationships – not only making clear and engaging visual artefacts, but also getting to know the people we need to work with to help make designs a reality
• Design is Planning and Organisation – the most junior designer must be able to manage their own workload, and as they get more senior they take on greater strategic responsibilities, and organise others to deliver their designs
• Design is Analysis and Judgement – knowing what techniques to use, and when, even with conflicting sources of information. The more senior the designer, the more this judgement comes to the fore.

There’s another factor that affects the NHS pay banding, called Freedom to Act. Our job descriptions set out the level of empowerment that each level of designer is expected to have in order for the organisation to get best value from their skills, knowledge and experience.

For example:

• Design assistant (band 6) is directly responsible for the design outcome of their work
• Associate designer (band 7) plans their own work within the remit of their assignment within the product team
• Designer (band 8a) knows when to apply the relevant policies and guidelines and when to deviate from them
• Senior designer (band 8b) acts as the final arbiter for design decisions within their product teams
• Lead designer (8c) works autonomously, often in areas of novel practice, seeking advice from peers and industry experts outside the organisation.

Designers in a large organisation can easily be disempowered. Sometimes their managers or teammates don’t give them their freedom to act. Sometimes, it turns out that they’ve had the freedom but didn’t realise it, or were afraid to use it. Either way, we have a problem, and we’re wasting public money. In the coming months, I’m planning to spend more time talking with designers and their managers about freedom to act.

The senior designers have taken on the task of organising our quarterly team events – the last one in London, and the next one in Leeds. While we spend most of our time embedded in the different directorates and teams, it’s important to get together as a community of designers across the whole organisation.

Giving control doesn’t mean giving up on governance. The service manual, with components and patterns alongside it, is there to speed up delivery. We found we needed some lightweight governance to make decisions, when they’re needed, about overall design quality, interconnected design work from different teams, and what goes into the manual. So we’ve set up a design governance board, bringing together the right people on an ad hoc basis to review work that could be of value to more than one team.

It’s one of a number of ways, alongside the weekly design huddles, that we maintain cross-team visibility of what others are doing. Having these forums helps me trust teams to get on with their work, and rely on them to bring things in for peer review or expert guidance when they need it.

Standards and design governance help us to design things right. Service design takes the lead when it comes to making sure we design the right things. We’re still finding our way with service design, but we now have practitioners embedded in 4 different directorates or sub-directorates across the NHS Digital organisation chart. Service designers add the greatest value when they have licence to work broadly across a portfolio, such as Urgent an Emergency Care. I’m sorry that we haven’t been able to create this space for all the service designers we have brought into the organisation.

Over the last 6 months, I’ve mostly managed to keep my commitment to spending at least 2 hours every six weeks observing primary user research. There’s always something surprising and worthwhile to see and hear. We’re lucky to have Rochelle and Gemma and their team of user researchers.

One of the highlights of the past few months has been welcoming a new cohort of Digital Service Delivery graduates on a 2-year programme in which they’ll get to try out working in user research, design, content design, product and delivery management. For next year, we’re recruiting a first ever cohort of user-centred design graduates, who will focus on user research, design and content specifically. Our CEO, Sarah, has been a champion for apprenticeships and graduate trainees, and thanks to Amanda, our head of profession, we now have the strength in depth to be able to look after a larger number of trainees.

I’ve tried to make time to keep an eye on the future too. Thanks to Cassie for inviting me to Nesta’s event on “collective intelligence” in September. I found it a timely counterpoint to the tech determinist narratives around “artificial intelligence”. This in turn shaped the talk I gave at Interact 2018. (Here’s the video and my write-up of that.) I think the other speakers and I were mostly in violent agreement. For the Interact talk, I also drew on the principles in the initial code of conduct for data-driven health and care technology. A new version of that is due to be published soon.

I was also honoured to be invited to talk at Health Product People at the Department of Health and Social Care, especially so because I was on the same bill as Hadley, Ian and Kassandra, all of whom were brilliant. I loosely titled my talk “Stop disempowering people.”

3. What’s next

I still wake up every day with a sense of wonder that I get to be head of design at NHS Digital. It’s a massive privilege. I’m also in awe of my talented colleagues, who could no doubt command gigs in many more glamorous brands and sectors, but choose to work on stuff that matters. I hope never to take any of them for granted.

Meanwhile things are changing in the organisation. We have some new leaders. The matrix management structure, of which I was never a massive fan, is being dismantled. A simpler, clearer, and hopefully faster, directorate structure is taking its place. Along with other senior managers in NHS Digital, I’ve had to reapply for my job. (Good news: I passed!)

At times during this transition I have felt an odd mix of responsibility without power and power without responsibility.

• Responsibility without power, because I still feel responsible for the team I was hired to lead, but in the new structure, I have lost some of the levers I previously had to help them.
• Power without responsibility, because, thanks to the tech vision, insights on user-centred design and digital are more in demand than ever across the wider health and care sector, but the programme and line management structures of my own organisation are still on a journey to reflecting that.

Amanda, the head of profession who hired me, is now leaving to take up a digital director role in the charity sector. I will always be grateful to have had Amanda as my manager here. Uniquely, she empowered everyone who worked for her, making the space for me and the other deputy heads of profession to grow in confidence and expand our teams. I’ve been given the opportunity to cover as interim head of profession, looking after product managers, delivery managers, user researchers and content people as well as designers.  This I will do with a sticky note on the inside cover of my notebook that reads: “What Would Amanda Do?”

I always said this was a multi-year commitment, and as I head into the second half of year two, this job is not done yet, not by a long chalk. In the next 6 months, alongside working on the most pressing and worthwhile transformation portfolio in the world right now, I hope to:

• Challenge more on design quality and performance across all our products and services
• Kick off some work on user experience strategy across the wider health and care system. User experience is not the whole answer, but it’s a good place to start understanding Why Doctors Hate Their Computers
• Further raise the profile of design and the other digital profession roles in the NHS, including a keynote at Service Design in Government 2019
• Look after my own long-term professional development, by applying for the Nye Bevan Programme of the NHS Leadership Academy.

I’ll let you know how it goes.