Challenges and changes – some notes for a panel session on delivering services

I was on a panel at the Digital Urgent & Emergency Care Conference, brilliantly chaired by Emma Mulqueeny. I wrote these notes as prompts for my contribution. Not everything here came up in the discussion but I thought the notes worth sharing anyway…

The NHS Long Term Plan reflects society’s expectations of technology in all aspects of health and care, for patients, the public, and for staff. These expectations have risen massively in the last 10 years, and will only rise higher in the next decade.

Meanwhile, a former colleague recently discovered that his diagnosis of diabetes type 2 wasn’t disclosed to him for more than a year – because his test result was hidden by a scroll bar on his GP receptionist’s screen. He found out after the practice bought a bigger monitor.

These shocking failures of connected care are far too common. People are too tolerant of them because that’s the way NHS computers have always been.

So we have a tension: the science is ready to forge ahead with genomics, artificial intelligence, and personalised medicine; but at the same time we’re not getting the basics right in terms of clinical and administrative systems that are easy to use and adopt, and data being available at the point of care.

We can only be trusted to critically appraise the innovations of the future if we are honest about the failures of the past.

The good news is that this is fixable. You just have to look at the phone in your pocket to know that cheap, reliable, interoperable technology is possible in all other areas of our life. So, while recognising that health and care have unique characteristics, we need to ask ourselves why we can’t just use the basic tools and good practices that other bits of the public sector are adopting too.

The Secretary of State’s digital, data and technology vision commits us to delivering services based on the principles of user need, privacy and security, interoperability and openness, and inclusion. These are the constants that we need to hold whatever the future may bring.

What we’re doing

I look after a profession group of 140 user researchers, designers, content people, product managers, and delivery managers at NHS Digital. We’re leading the whole of our organisation on a journey to work in a more user-centred, agile, iterative way.

We always start with user research. Often we find that what users really need isn’t the thing we thought they did, so that saves money right away – by not wasting it on a solution nobody needs.

We invest in design skills – graphic, interaction, and service design – throughout the process, so we get systems that work first time, ones that don’t require lots of training.

Count up all the hours spent on training whenever a new system is introduced, work out the cost in people’s time – clinicians’ time, administrator’s time, patient’s time wasted waiting while they work it out. And that’s the business case for investing is design and user research, to make systems that are intiutive and reliable.

Everything we build, we release as open source code, and we share our design principles and good practice on the NHS digital service manual because we want others to be able to freely adopt it and use it to solve the unique local or service problems that they know the best.

Users first, technology third

I worry when people come to us with magic bullet solutions like AI and blockchain, that heads will be turned and more money wasted without discovering what’s really needed. The answer to that is to spend more time listening to patients and staff, understanding what they really need. Their needs come first, service design second, technology third.

I worry that we won’t fix the basics to a high enough standard because people – with the best of intentions – still have very low expectations of NHS technology. The work we do on our national services, like the NHS website, the NHS App, 111 Online, has to be of top quality in both design and execution, because we set the standard for the locally commissioned tools and apps that will continue to make up the bulk of the patient and staff experience.

Sometimes a fashion for a technology comes along which seems like one thing on the surface, but really is something deeper. For example, voice assistants and chatbots are often presented as a user interface choice, but actually the idea they represent – that you can have a conversation with a service in human terms – is much more powerful than that.

The challenge is to rethink how the whole service is configured to make it more responsive and personalised. That’s about understanding the person’s intent much better than we do at the moment, and having the capabilities to wrap around that intent.

At the moment our staff do that every day when they deliver care, often in spite of our systems not because of them. If we’re going to ask technology to play a greater role, we have to respond to people’s deep desire – indicated by the popularity of these new UIs – for a more human experience of the service.

Building blocks to embed user experience:

First we have to have the capability to know what a good user experience looks like. At one level, this is self-evident, but when we bring in technology and the sheer scale and complexity of the service we run, we really do need to professionalise user-centred design leadership. This is not a domain for gifted amateurs.

Second, we need to set a clear quality threshold and set of expectations. The Government Digital Service did that with the service standard. We have the beginnings of it in our tech vision.

Third, once we have those things in place, capability and clarity, we need to give our user experience specialists the freedom to act. They need to be able to say to anyone in the system, as far as the minister if necessary, there’s a better way to achieve that outcome.

That’s something that has been very refreshing about the current Secretary of State’s approach: he is very focused on the experience both of patients and staff, and he will articulate the outcomes he wants. But he does trust us – all the people in the room here today – to experiment and arrive at the right solutions in the contexts that they know best.

Medicine thrives on experiment – and so does design

Innovation is all about relationships – between people, between organisations, even between new tools and technologies. The problem is that as an organisation gets older and bigger, the mass of existing relationships and ways of doing things starts to crowd out the space for new thinking.

So we need to consciously create that space, and hold it even when things seem to be going wrong, which is when people are likely to revert to old habits of caution and control.

We’ve been able to deliver the new NHS website, the NHS App and 111 Online because some senior people held the space for us. Now we need to hold the space for others too, to take that work even further.

Video of me talking about the event…

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