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.

00 cover.jpg

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…

09.jpeg

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

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

17 copy.jpeg
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!

Advertisements

“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.

Who wants to be a story millionaire? Some thoughts on the value of Patient Opinion

So, narrative capital. The social scientist has it like this…

… the power [research participants] have to tell the stories of their lives. This ‘narrative capital’ is then located in the ‘field’ of social science research and Sen’s capability approach is introduced to prompt the question: What real opportunities do research participants have to tell the stories they value and have reason to value? It is argued that ‘narrative capital’ can be too easily squandered by the failure to recognise individual values. –Research Abstract, Michael Watts

… and the novelist like this…

What the writer accrues by setting up situations, tensions, threats and other build-ups. If the author decides on a shocking climax that blows everything wide open, they will be spending the Narrative Capital they’ve saved – having the warring couple suddenly acknowledge their love, for instance. The more capital saved, the better the climax – but you can’t spend the same capital twice, and if you try to have a climax bigger than your capital can buy, the audience feels robbed. – author Kit Whitfield’s lexicon

I invoked the idea of narrative capital on this blog when I wrote about the wanton destruction of Leeds’ historic Clarence Dock: You wouldn’t burn a book, so why destroy a place with so many stories?

And last week at our first ever Service Design Thinks in Leeds I was struck once again by the power of stories, thanks to James Munro of 4IP and Screen Yorkshire-supported Patient Opinion.

Patient Opinion is a simple idea: you can write your account of being a patient in the UK’s National Health Service, read other people’s experiences and, crucially, see what NHS staff and managers are doing to make things better.

Making things better is at the core of the service: it’s founded on the insight that the NHS is well-equipped to deal with adversarial “complaints” demanding specific redress, but less so for “feedback” – negative and positive comments freely given by people who simply want to help improve the service for future patients, some with very specific suggestions, others just to say thank you.

With the help of this social enterprise, health service managers and practitioners can hear their patients’ authentic and surprising voices more clearly, and deliver better care as a result.

And at the centre of their operating model are stories. Lots of stories. Stories that have value, donated like blood:

100,000 stories per year. After 10 years, you could be a story millionaire!

It would be tempting to throw the Patient Opinion corpus into some kind of massive algorithmic natural language grinder, to present yummy infographics and Chernoff faces showing the relative happiness of different institutions, like Patient Opinion’s 4IP stablemate Schooloscope.

But that would miss the point. Yes, the Patient Opinion stories are cumulatively impressive – 25,017 and counting – but, as James explained, their power is in their uniqueness. Each story is different, nonfungible. Each narrative is differently shaped and demands a personal response from specific people.

Story, narrative capital, content, call it what you will. The value is not in the words themselves, but in the minds and actions of the “audience”: the right people in the right place hearing the right stuff at the right time, and doing something about it.

You can watch James Munro’s talk on the SD Leeds Vimeo channel.

Service Design Leeds, from Drinks to Thinks

There are lots of reasons to come along to Leeds Service Design Thinks on Tuesday 14 September. So many that it’s hard to know where to start.

I could begin with the chance to meet and chat with some of the smart and passionate service designers who made it to our first Service Design Drinks event back in June, and some more who’ll be joining us for the first time. It was a bit of a gamble to bring this format to Leeds, modelled on successful events in London, Glasgow and elsewhere, but it paid off handsomely. We discovered there’s lots going on already, and lots of interest in developing a northern community of interest around service design and design thinking.

But starting there would be to neglect the fact that on September 14 we’re giving you the chance to hear from Dr James Munro about his social enterprise, Patient Opinion, and the challenge of building better services in the NHS. James already presented his work at Service Design Thinks in London, and we know it’ll be of interest to many people working in the North. I’d give up my Tuesday evening just to hear from James.

But that might give the impression that service design is only for public services and social enterprise. It’s not. We also have my Orange colleague Kathryn Grace presenting her work on retail customer experience. As a designer for a company called Everything Everwhere, Kathryn has a unique viewpoint over in-store experiences, large-scale e-commerce and e-care, and cutting-edge mobile applications. I know she’s passionate about making all these things work together to deliver a simple and engaging customer experience. Kathryn also deserves the credit for making this whole event happen in the first place. Tero and I have played supporting roles, but hers is the main drive and motivtation behind both “Drinks” and “Thinks”.

And if you’re still wavering, consider this. Not one, not two, but three amazing speakers! For we will also hear from Professor Guy Julier of Leeds Metropolitan University. When we set up SD Leeds we wanted to explore how service design approaches could make a positive difference to the place where we live and work. So Guy’s role in the Leeds Love It Share It community interest company is right up our street. He’ll tell us about “Margins within the city” a recent community development project.

There’s no end to the fascinating questions that arise when we consider these three topics together. When designing a service, where do you start? Who do you start with? And what kind of people and processes make a new service more likely to succeed? That’s why we’ve tag-lined the event “Starting Points”.

“Service Design Thinks Leeds 01 | Starting Points” is on Tuesday 14 September, from 6pm to 9pm, at a central Leeds venue to be confirmed. You can sign up now on Eventbrite, follow us on Twitter, or find out more about this and other similar events on servicedesigning.org.

Maybe it’ll be the start of something new.