Levelling up: Two and a half years into my work at NHS Digital – part 1

Wall with A4 printouts headed

I’m starting to write this on a sleepy Friday evening train back to Leeds, two and a half years and one day since I started at NHS Digital. I won’t publish it for a week or so now, out of deference to the pre-election period. This morning at Leeds Station I popped my postal vote in the pillar box, just before boarding the 7:15 train to London. Whatever the outcome on 12 December, by the time you read this, public servants all over the UK will be exercising their innate talents for responding to change over following a plan.

I took a bus from King’s Cross to Elephant and Castle so I could stay above ground for a call with Nuremberg-based Global Service Jam legend Markus. He has exciting plans for next year, which I hope I can play a small part in.

At Skipton House, NHS Digital’s London base, I shared a meeting room with Simon from NHS X as we took part in a call with corporate portfolio office colleagues from both our organisations, remotely yet expertly chaired by Iain.

Then I went down to the atrium to chat with a brilliant product lead who I hope will be tempted to join us for an important new piece of work.

On the way back to the station, I took a detour via GDS at Aldgate for a coffee with someone who wanted to know what it’s like to work in digital for health and care. I’m two and a half years in, I told him, and I’m still learning new things every day.

A big part of my learning this year has been through the NHS Leadership Academy’s Nye Bevan Programme. I’m saving that for part 2 of this post. In this one I want to talk about progress in the multi-year mission to grow people-centred strategy, capability, tools, and culture inside NHS Digital and across the wider health and care system.

Scaling out

Revisiting my two-year note, I can see that I was not-so-subtly telegraphing a set of demands to my organisation – for the licence to work across a wider scope of our products and services, and for design and user research to be in the room more often when decisions are made. Six months ago I wrote:

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.

To my surprise as much as anyone else’s, my leaders agreed.

Back in June, Wendy, the executive director for product development, invited me to create a new model for design and user research, and to present it to her directors’ strategy day.

I told the directors that user-centred design thrives in multi-disciplinary teams. Most of our designers and user researchers are embedded in them – close to where the work is, and helping product managers to make better decisions.

But, as Kristin Skinner and Peter Merholz note in ‘Org Design for Design Orgs’, 100% decentralised doesn’t scale. It means that user-centred design tools and operations are replicated in silos. Duplication costs us more and confuses our users (both patients and staff) when things designed in isolation don’t work well together.

This problem was accentuated in our case because all our most senior user-centred design staff were concentrated in one part of the directorate, working on citizen-facing services, while the organisation’s services for health professionals lacked design oversight.

We’d reached the point in our design maturity where Skinner and Merholz’s “centralised partnership” model looked like a good fit. This is how I drew it:

Diagram showing

The directors agreed. Helen, who was leading on strategy for the directorate, and her business management team provided practical support to make it happen.

Walking the floor

Six months later, Wendy has moved on, leaving me on the product development senior leadership team in the new role of associate director of design and user research. I’ll always be grateful for Wendy’s support, and I’m sad not to have the chance to work with her for longer at NHS Digital. Helen also left around the same time; I’m determined to keep working towards the strategy that she outlined for our directorate.

Rochelle and Tero being promoted – to heads of user research and design respectively – has instantly tripled the number of user-centred design specialists who sit alongside programme and service heads in the directorate extended leadership team. They’re already getting to work across the different sub-directorates to broker earlier involvement of user researchers and designers, at the right levels of seniority, and to set high standards for how we research and talk about user needs.

We’re also creating a small central team to coordinate across the 70 or so user-centred design roles that are starting to spread more consistently through the full range of our products and servicess.

The difference is palpable, spatially, as I walk the length of the 8th floor at Bridgewater Place, where the majority of our Leeds-based product development people work together.

Starting at the north end facing the railway station, is the NHS.UK team, whose user-centred design practices were already well up and running when I joined, coincidentally in the week of the 2017 election. It’s a sign of success that this service is moving to live, with an emphasis on continuous improvement and responding to the changing needs of the health and care system. Not so long ago, this would also have been where our user-centred design tour of Bridgewater Place would have ended.

Now, just across a clattery bridge across the atrium, is the NHS App, with a growing number of permanent staff working in blended teams with our suppliers.

Walking down the west side, with views out over Holbeck to Armley, I pass the small team preparing for discovery on book, refer and manage appointments. The name is a bit of a mouthful, but it’s important not to let it turn into an acronym before we even know what the scope is.

Three of our Digital Services Delivery graduate trainees sit nearby working on a ResearchOps discovery under the watch of senior user researcher Matt. If we get this right, our researchers will be freed up to spend more time understanding our users, supported by the firm foundations of research infrastructure and community.

To one side near the kitchen is the accessibility lab space where teams will soon be able to test their products on a range of assistive technologies.

On the wall just before I get to reception are the outputs of the digital urgent and emergency care research, on which we partnered with Futuregov.

Heading south after reception past General Practice Information Technology, I get to the desks now earmarked for the central UCD team to sit together. It’s great to catch up more often with Tero, Rochelle, and Dean, even better when Nancy joins from London on a video call.

Tucked away around a corner is our wall, with A0 plotter-sized posters of Tero’s service taxonomy and system-wide patient experience map of health and care.

And across the way are the growing team working on screening. Rochelle and Shirley’s pioneering work in discovery has led to more designers and researchers joining that team as delivery ramps up.

We also have user-centred design professionals embedded with teams working on NHS login, 111 online, maternity, referrals, and pharmacy among others, as well as over in the Digital Delivery Centre. As profession lead, I’m proud of them all.

Design and user-led

User-centred design at NHS Digital is scaling out and levelling up, but there’s still more to do. As a user-centred design team, we’ve signed up for three missions to help make the whole product development directorate design and user-led. We’ll work to make sure that:

  1. there is user-centred design leadership across product development and all sub-directorates – we now have user-centred design leads for two of the four sub-directorates, and we’re discussing with the leaders of the other two, as their scale and scope of their services is still emerging.
  2. our teams understand principles and approaches of user-centred design and have had access to relevant training – Tero and Rochelle are rolling out a one-day introduction to user-centred design training course for all our colleagues, and we’ve set a target for everyone to have exposure to primary user research and assistive technologies.
  3. our new programmes are established as exemplars; from the start we establish design thinking and agile processes, including governance and funding – we’re focusing first on getting this right for three priority areas – the NHS App and login; screening; and book, refer and manage appointments.

It’s important that we show some tangible outputs for this investment in the central team. These are likely to include:

  • Updates to our design principles, co-created in beta two years ago with a small group of designers from across the system. They’re due a refresh based on everything we’ve learned together since.
  • Ways to make user research insights more visible and actionable across multiple teams.
  • A user-centred list of services, along with prototypes that cut across the historic programme silos, as so many user journeys do. Some say good fences make good neighbours, but user needs run like a river that respects nobody’s territory.
  • Continued development of the NHS.UK Frontend, which proved its worth when the team were asked to build a user-centred, responsive, and accessible launch website for NHS X in just a couple of weeks.

A product mindset

Design and user research leadership is only part of an overall operating model with a much stronger role for product managers, who are also part of the Digital Services Delivery group for which I’m profession lead.

The modern digital product mindset is a trifecta of user-centred design, agile multidisciplinary teamwork, and devops engineering practices. In conversations with colleagues across the directorate and beyond, I’ve been trying to articulate what we mean by all three, and how they fit together.

This has big implications for how we plan and manage our portfolio. This is what I’m currently advocating, informed by some of my Digital Services Delivery profession colleagues:

  • Digital portfolio management should be agile by default. The portfolio itself must be managed in an agile way, and decision-making processes aligned with the values and principles of the agile manifesto. Role definitions for the people involved should follow the Digital, Data, and Technology (DDAT) capability framework.
  • Professional product management is the connective tissue between over-arching NHS Long Term Plan-level commitments and the everyday work of our multidisciplinary teams. It’s the job of service owners and product managers to keep focus on the big picture, even as they work with teams on the detail of delivery. Product management artefacts such as the product vision, roadmap, and backlog exist at multiple levels, and enable more agile, multi-disciplinary decision-making throughout.
  • Not everything will be agile, but discovery should be mandatory regardless of delivery style. Dependencies should be designed out, not only identified and managed, and we should expect our future “buy” processes to be as agile as our “build” ones.
  • We should be clear what it means to “close” a project or programme. While programmes are temporary, planning must cover the whole lifecycle, from live through to the “retire” stage, which only occurs when the service is no longer needed. Because benefits and outcomes are under the leadership of product management throughout, the move to live should be a smooth transition, not a disruptive handoff.

Leading change

A big part of the summer months were taken over by organisation change as I was “proposal for change lead” for my profession group. To lead with care when people’s jobs are at stake requires constant sensitivity and attention to detail.

Content, design, and user research roles were in scope for this wave of change. If you’ve been paying any attention to the series so far, you’ll know by now that these are all roles we need more of for the future. This meant that most people could be immediately “slotted in” to roles in the new structure. Even so, the process was inevitably unsettling for people as they waited to have that confirmed, and a small number of people were put at risk of redundancy due to NHS Digital’s location strategy.

I couldn’t have completed this wave of change without the support of Ian, the profession’s executive sponsor, and the brilliant practice leads, especially Eva, who stepped in when the publication date for the proposal fell right in the middle of my two-week family holiday. The unsung heroes of organisation change are the HR and business management colleagues who keep on top of staff records and spreadsheets to make sure that the data on which decisions are based is correct, and stays correct.

As we worked through this wave, we’ve also been preparing for the next one, when the product and delivery management side of the profession will be in scope.

At times the practical and emotional demands of organisation change have felt like a denial of service attack on my ability get any of my other work done – even though, compared to some other change leads, my task was relatively straightforward. It’s important to keep sight of the purpose of all this: to equip our organisation with digital, data and technology skills for the future, so we can better serve patients, the public, and the wider NHS. Behind every number on a spreadsheet, there’s a real person with skills, experience, and career aspirations.

(Note to future self: never undertake organisation restructuring at the same time as significant house renovations. The new kitchen is lovely, but you need to have stability somewhere!)

The other side of being a profession lead is working with the always inspiring practice leads for each of our roles to develop professional standards and communities of practice. For professional standards, we align as much as possible to the DDAT framework.

For communities of practice, we’ve stepped up collaboration across the health arms-length bodies. All five of the Digital Services Delivery communities have run events in the last 6 months, all of them self-organised by members of the profession, and all of them with participation from wider health system professionals as well as NHS Digital people. Going back to the beginnings of my time at NHS Digital, I identified “designers talking to each other” as one of the essential foundation stones of joined-up user experiences. This applies at system scale, as much as inside any one organisation.

Looking to the digital skills we need across health and care, I’ve been acting as interim programme head for NHS Digital’s bit of the Building a Digital Ready Workforce Programme. This means I get to talk professionalisation with James at Health Education England, and the blended team across our two organisations (three when we add in NHS England’s Digital Academy). This small, quietly committed group is a model of cross-system working that many others would do well to emulate. I hope I’m able to bring a different perspective as someone still relatively new to health, and having been involved in DDAT since pretty much the beginning of the framework in the GDS Capabilities Team.

A highlight in September was welcoming our new, and biggest ever, cohort of graduate trainees, in two tracks – user-centred design and product & delivery. I’ve been meeting regularly with one of them as a “career mentor.” I reckon I learn as much from Misaki as she does from me. Talking with people at the beginning of their user-centred design careers challenges me to separate core principles of the craft, which they’ll carry with them through their whole working lives, from the specific skills that they need in digital today, but that could be obsolete in just a few years’ time.

Looking outwards

Hours before the start of the pre-election period, Nicola released a draft of new guidance on how teams should involve people (patients, carers, citizens, the public – words matter and all have their place) in all our work. I’m grateful to the many people who have contributed so far – both members of the public and my colleagues from NHS Digital and NHS X.

The NHS Constitution is clear on this, and there are many resources available which we don’t want to duplicate. But we in digital haven’t always done it well enough. As I reflected for Matthew Gould’s blog post, people in national roles can be scared of public engagement, because we don’t always know how to do it well, and we fear that it may derail our existing plans. The guide we’re working on is intended to help teams overcome that.

This is in addition to, not a substitute for, primary user research. Except for the summer holiday period, I’ve kept up my commitment to getting my own 2 hours every 6 weeks, and always learned something new by sitting with teams in the observation room. In an act of public micro-accountability, I note the date that I last observed research on my Mastodon and Twitter profiles.

As I mentioned in my 2-year update, I believe we can all be more effective inside our own organisations by staying connected with the world outside. For me this has included:

  • Catching up with the other government heads of design – several of them also now deputy directors – at the Cross-government Design Meeting in Leeds
  • Being part of the Arms-length Bodies Digital and Tech Leaders group
  • Joining a panel at the Healthcare Excellence Through Technology show to talk about user experience for mobile apps in health and care
  • A visit to Durham University with our CEO, Sarah, and other NHS Digital colleagues, to talk about our graduate programme and other potential collaborations
  • Talks at Camp Digital and IXDA London
  • A speaking engagement alongside Misaki at an NHS Digital industry event to talk with suppliers about standards for user-centred design in health and care.

In one way, counting two and a half years in a job feels superfluous, not even a full anniversary. On the other hand, it’s a quarter of a decade, roughly one tenth of my working life so far spent full-time in health and care. Am I an insider now? And if so, how does that square with my personal mission to change how we do things around here? In part 2 of this post, I want to share some of the learning I’ve achieved as part of the Nye Bevan Programme.