Worlds colliding – reflections 2 years into my work at NHS Digital

Diagram of health user journeys with loops and arrows between different states of health

In a breakout room to the side of the Service Design in Government conference in Edinburgh, with a floor to ceiling view of Arthur’s Seat and a lawn where alpacas were led to graze, I chatted about service maps with a small group of my brilliant NHS Digital colleagues. I felt a little guilty keeping them from the lunchtime networking of the conference, but sometimes a change of scenery is what we need to change the conversation.

During the 6 months leading up to my second work anniversary this week, several moments have felt like those season finales in which apparently separate plot strands twist together to reveal where they were heading all along:

  • At Service Design in Government, Sophie cleverly scheduled me to talk service design in health as a warm-up act to the challenging perspectives of Ade Adewunmi and Cormac Russell.
  • In Digital Urgent & Emergency Care, we’ve hired a proper service design agency (Futuregov selected from a strong field of Digital Outcomes framework suppliers) to work with our own people in a blended team on one of the toughest parts of the NHS’s transformation portfolio.
  • At Sprint Leeds, my long-time service jam collaborator and now GDS’s engagement manager Lisa Jeffery took the stage as host alongside former NHS colleague Eve Roodhouse, now running economic development at Leeds City Council.
  • Just this week, GDS have published a guest blog post by my colleague Dean on adapting the GOV.UK Design System for the NHS.
  • And on the first floor of Skipton House in London, the NHS England and Department of Health and Social Care teams, which my team and I used to shuttle between, are becoming one and the same as part of NHSX.

New website

Having made the switch from NHS Choices last September, we’re learning what this new site, and new way of working, can really do.

Last year, we went through a tricky phase as a programme of getting our backlog and our budget under control. It’s hard to be either user-centred or agile without clear visibility of those.

Now we’re in better shape. The NHS.UK senior leadership team has come into its own. When there have been tough decisions to make quickly, we’ve really benefited from the multidisciplinary nature of the team – heads of product, delivery, tech, design, content and clinical around the same table, or at least on the same Skype call.

We have a clearer view of our audience, thanks to some work with Fjord.

And we worked with Nomensa to clarify our ambitions and plan to make the website more accessible. We know we have more to do on this, but now have an action plan and much greater awareness of accessibility issues across our teams.

The work of transforming the NHS website won’t be truly done until we’ve addressed our information architecture. While the new look we launched in September is fully responsive and much more accessible, it still has basically the same structure as the NHS Choices site it grew out of. Fortunately this is something we’re prioritising in 2019-20.

Another unloved section of the site which needs attention are our service finders. Trilly, Esteban and team are working on those now, starting by clarifying what exactly we mean by “service’. I have opinions about this and am trying not to lay them on too heavily.

We now have a family of NHS website, NHS app, NHS login and other public-facing services. (I count the simple naming approach as a win from 2018 :) Under the leadership of Ian, our director of Citizen Health Technology, this portfolio is entering a new phase which demands two important changes.

First, we’re moving from limited-exposure alphas and betas to a set of core products and platforms that are live to millions of patients and members of the public. This opens up the possibility of a much more data-informed, iterative approach to design and delivery. Analytics and devops capabilities will make this suite of services really sing – changing, growing, and adapting in response to user needs at scale.

Second, we’re moving from a set of separate minimum viable products to services that work coherently across user journeys. Service design is of course central to any such change. Getting service designers freed up from the programme silos to take a broader view has been an on-going focus for me. I think we’re nearly there.

As I wrote about going live not long before joining the NHS, we should think of discovery as a culture, not just a phase.

I’m really enjoying the burgeoning community around our NHS.UK Frontend and service manual. No one has been mandated to use either – they’re still very much in beta and we welcome your feedback. But they are being adopted by multiple teams in NHS Digital, other national NHS organisations, and in teams transforming services locally – because they meet genuine needs, spontaneously identified in situ.

Likewise our design principles, co-created by designers working in the NHS. It’s always a pleasure to hear teams refer to them, and to see the posters crop up in the wild on social media. Our design principles should be a bridge between the NHS Constitution and the much-imitated GOV.UK Design Principles. They signal our intent to be 100% of the GDS world, and also 100% true to the values of the NHS.


Modelling my classic NHS hoodie – artwork my recreation of a 1948 government leaflet. Available to buy now at Terence Eden’s Govgeeks Spreadshirt store

New leaders

Juliet and Alan, who between them led the NHS’s citizen-facing digital services for most of my first 2 years here, moved on within a few weeks of each other. I’m grateful to them both for creating the space in which we’ve been able to design and deliver so much.

I’ve had to figure out what the new leaders taking their place want to achieve, and to make sure that design and user research are able to support them. Wendy, our executive director for product development is great. You should follow Wendy on Twitter.

As a user-centred design group in NHS Digital, we’ve continued to lay the foundations with essential artefacts such as the design system, a service map and user research repository. The three leads, Dean, Tero, and Rochelle, are all stars, who are better than me at the things they do. I was sorry to say goodbye to Gemma as lead user researcher on NHS.UK, but pleased to report that Nancy has now joined us in her place. Welcome to the team!

We’re not yet across the whole of the product portfolio, including some of the critical services used by clinicians and health service administrators. That’s something I hope to address in the next 6 months.

I’ve been watching the way colleagues in other parts of government are taking design and user research up a level in their organisations, and am determined to do the same in the NHS.

New power

In my 18-month update, I referred to the disconnect between power and responsibility in my role. In the past 6 months, this has been thrown into greater relief.

The change we need in the NHS demands a blend of old power – small groups locked in rooms making high stakes decisions about multi-million pound budgets – and new power – spontaneous self-organisation around the principles of user needs, inclusion, privacy and interoperability.

Having a modicum of each sort of power myself, I believe that the people wielding both do so with the same basic good intentions.

At times I’ve had a seat at the table where tough decisions were taken. When we meet behind closed doors, there is never enough information in the room. All we can do is hope we’ve done enough to truly understand the outcomes we seek and the implications of the choices we make.

On other occasions, I’ve peered in from the outside with my clan of social media-savvy design and healthcare radicals, and feared that the good work we nurtured between the cracks in the old system might be accidentally trampled underfoot by people trying to create the new.

To bridge those worlds, we constantly have to tread the line between courage and stupidity. Tread that line we must, because the process we use to get to the future is the future we get.

Working in the open

Regular readers will know I’m militant about working in the open. I’ve taken this up a level by committing to write public weeknotes on a regular basis. Having tried this and failed before, I now limit myself to a few simple questions. (Thanks to Sam for the definitive survey of weeknote styles which I used to choose my format.)

After a 10-week streak of consecutive weeknotes I tag-clouded the things I noted that inspired me:


Tag cloud of things that inspired me. Biggest words: nhs, design, digital, people, team, service

Perhaps unsurprisingly, the same words also figured highly when I asked myself “what do I need to take care of?”

In a recent weeknote I reflected on why I write these notes (mainly for my own benefit not others), but also how this might be perceived others.

I need to work in the open to advance the cause of user-centred design across our complex health and care system. I also need to be present for my team and NHS Digital’s own leaders. It’s not an either/or: everything I do in the system also makes me more effective as an operator inside my own organisation.

As a learner, I frequently share work in progress, and things that are puzzling me, with my network inside and outside the organisation. This is not so much external influencing as using people’s collective brilliance to shape my own thinking and challenge myself. It plays directly back into the work I do with our own teams.

But I need to be mindful of how this may come across to others who have not had the privilege of being able to work so openly for so long.

There’s another, values-based, reason why public weeknotes are good practice as a public servant. It’s so easy in big organisations to talk about others behind their backs, to have one message in one room and another in the next. I know I’ve been guilty of that in the past. Working in the open constrains us positively to say things that are meaningful and respectful to everyone involved, including, of course, the patients and public we’re here to serve.

People (not resources)

6 months ago, I was picking up a role as profession lead for our Digital Services Delivery people – 140 or so product managers, delivery managers, designers, user researchers, content designers and editors. We’re a subset of the user-centred design and delivery roles found in the Civil Service Digital, Data and Technology (DDAT) profession to which we align.

The profession is responsible for the communities of practice around each role, for job descriptions, training, and professional standards. Luckily I have practice leads for each of the roles, all of whom are among the organisation’s most knowledgeable, committed and growth-minded people. I couldn’t be profession lead without them.

A definite highlight was working with profession members to select our new cohort of user-centred design graduates, who will start a 2 year programme with NHS Digital in September.

Having been here for 2 years, I’ve now had the privilege of seeing several people move up through the bands, from junior to practitioner, to senior, and to lead.

Meanwhile NHS Digital as a whole continues its organisational transformation. There are lots of positives in this for our digital specialists. But, for every one of us involved in running the change process, it’s a test of the quality that the Healthcare Leadership Model calls “leading with care”.

I have been challenged, and I hope challenged myself, on the diversity of our profession, which does not fully reflect that of our patients or professional users. I know I’m not alone in wanting to address this, but it will require continued focus to live up to the values of the constitution, even when it means putting in more effort, questioning existing processes, and potentially taking longer to fill roles.

More generally, we need to offer opportunities to move into digital roles for people in other parts of the organisation. I know from my time at GDS and the DWP Academy that many people have the capability to do these digital roles – as long as they’re given the learning opportunities and working environment to do so.

My role includes working with other profession leaders to explain what Digital Services Delivery people do, and how we work differently from the more generalist, project-centric teams that the organisation has had in the past.

Digital Services Delivery people work in multi-disciplinary teams, and self-organise around outcomes. We achieve flexibility through teams that stay together as they follow the value, rather than pools of interchangeable individuals who are disbanded and reassigned each time priorities change.

Cutting across these self-organising teams, our developing specialists need support and challenge from more senior line managers in the same skillset. That’s easy to achieve in the parts of the organisation where we have a critical mass as a profession. It’s harder to pull off in places where our roles and ways of working are still in the minority.

To their credit, our directors, HR team, and the other profession leads have all been willing to consider my suggestions, even when they run counter to long-established assumptions about how things get done around here.

In the next 6 months, I sense an opportunity to link up DDAT professionals across the whole of the health service too.

Patiently engaging

At the end of my Service Design in Government talk, I was asked how we would go about changing the attitude to design across a system as vast as the NHS. My answer was that we need to get out of our design bubble.

For every talk I give at a digital sector event like Camp Digital next week, I aim to give at least two at health and care events – ideally the ones where I’m not preaching to the converted.

I was delighted to be asked to speak at a Royal Society of Medicine event on medical apps, and at the Digital Urgent & Emergency Care conference. The forms expert Caroline Jarrett and I presented jointly at the Empower the Person conference. And I had the pleasure of talking with Marcus Baw, Greg Burch and Victoria Betton about open source in health and care.

Whenever I go to those events, I’m struck by the interconnectedness of the service experienced by patients and the public and the systems used by clinicians and practitioners.

We need to make health information open and understandable to the people whose data it is, and we also need to do a better job of supporting clinicians to access and use that information as part of the care they deliver.

And if we don’t improve the experience of professional users who have direct patient contact, such as GP receptionists, there’s no way they will recommend digital self-care to the patients they serve.

One of the most moving and persuasive blog posts I read in the last 6 months was from @CancerMum, on the trials of gaining access to her son’s medical records. As the people charged with improving technology in the NHS, we should share her frustration and be motivated to try harder.

I’ve been privileged to represent NHS Digital in workshops with stakeholders including people from third sector groups which support some of our most vulnerable patients. While we have a good story to tell about improving the accessibility of our own services, there are still many barriers to digital for the people who could benefit from it the most.

As product development teams, we need to improve how we do patient and public engagement. This means more than researching with users; we ought to be involving people meaningfully in prioritisation and decision-making about our services. I think many people in digital teams are still afraid to do this, and we need to find ways to make it a natural part of our practice.

Here for the long term

Chapter 1 of the NHS Long Term Plan, published in January this year, began: “Compared with many other countries, our health service is already well designed.”

As the health service’s most senior human-centred design specialist, speaking as ever in a personal capacity on this blog, I worry that makes us sound more complacent than we have any right to be.

The truth is that most of this service was never consciously designed at all. It emerged through countless policy decisions and reorganisations. Someone responsible for part of the service made changes that seemed like improvements in isolation, but often had unintended consequences elsewhere. Every time we make another tweak, we risk making matters worse – unless we step back and consider the system as a whole.

The aspirations of the Long Term Plan are sound: more joined-up and coordinated care, more proactive services, and more differentiated support to individuals. And they’re crying out for service design approaches.

So in the next year, I want to make sure we take a more strategic view of user experience across the NHS. Some themes that should be central to this:

  • We want to push decision-making as close to end users as possible. But for impact and efficiency, we also need to design and deliver at scale.
  • Redesign of technology cannot be in isolation. It must be part of end-to-end service design.
  • The incentives of technology buyers and sellers need to be aligned with the interests of end users.
  • Modern agile, devops culture must be paired with user-centred design. That way, we will build the right thing, and build the thing right.

Our work on service design and standards will be key to all this. We also need to keep growing the base of skilled practitioners to apply those standards.

Recently, I’ve started working with Building a Digital Ready Workforce, a combined Health Education England, NHS England and NHS Digital programme. They’re already making me think differently about professionalisation for our DDAT specialists, especially those of us working at a national level.

I have a slow hunch about the relationship between design and the quality improvement movement in health and care. I’ve join the Health Foundation’s Q Community and committed to explore that further over the next few months.

So much more to learn

Not long after I published my 18-month report, I was interviewed for a place on the NHS Leadership Academy’s Nye Bevan Programme. In their feedback, the panel noted that I seemed very nervous. Looking back, I think that’s because I had realised at the last minute just how much I wanted a place on the programme and how gutted I’d be if I didn’t get in. I was accepted, and began the course as part of Cohort 24 in February.

Having come straight into a national NHS organisation just a couple of years ago, I’m learning loads from my more experienced local NHS colleagues on the Bevan Programme, especially about the formal and informal structures of this complex system. I’ve come to understand that the challenges we have of collaborating across the national health and care organisations are a parallel to the changes happening in localities with the creation of integrated care systems.

Every day so far on the Bevan Programme has been challenging and enjoyable, in large part thanks to our course directors Naomi and Majid, and learning set facilitator Caroline. Having done a little of what they do, I can see how skilled they all are.

I’m in a peer learning set with 6 colleagues from a range of different NHS organisations. They’re all brilliant, and I feel privileged to go on this journey with them.

In addition to meeting the 8 programme learning objectives, each Bevan Programme participant creates two personal learning goals of their own. These are mine:

  • Demonstrably improve my ability to set clear expectations and hold others to account, while leading with care through a time of organisational change.
  • Understand and evaluate paths to a board level role for me in the NHS, considering novel and existing roles, within and beyond my existing ALB landscape.

Wish me luck and send clues!

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