This was a week of two halves.
Monday and Tuesday were spent in an office with 60 or so people doing quarterly planning for the NHS App. It is a strange activity because while the nominal goal is to plan what the 12 NHS App teams are going to try to accomplish over the next three months, the NHS App is not a self-contained entity. For better or worse, it is the nexus of organisation’s wider plans. Planning what we will work on necessarily involves understanding what everyone else will work on, including which parts of that involve us. The question is how to align those goals, and which ones will take precedence when they conflict.
I don’t envy the work of product managers in this environment. To make good decisions about what work to pursue, they need to understand all of the attendant trade-offs associated with any given piece of work. When the list of items to review expands to cover most of the organisation, you can end up in a mess (or just very tired). Earlier this week I watched this video by John Cutler about an experiment he did to visualise how a team’s volume of work compounds the lines of communication problem. I can’t help but think about what the same concept would look like when you scale it up to an entire organisation. Terrifying. That’s the work product managers in this organisation need to do.
There is an analog for the work of designers who need to balance the many elements of the health system with devising an experience for users that produces the right outcome in a way that is cost-effective, efficient, and not a drag. It would be easy enough to solve that equation if you only needed to focus on a single variable, but to solve for them all at the same time is a complex job (insert line about five-dimensional chess, etc, as desired). Take cost savings as an example. If we make a service cost less, we can either save money for the organisation or reduce a barrier to using the service. Great! But if the service itself is not good in the first place, all we end up doing is producing a bad outcome for less money. Bad! In this example, the problem is that while reducing costs may benefit some actor in the system (likely the organisation that needs to run the service), from the perspective of the person in need of the service, you’re optimising for the wrong thing.
So we might say that trade-offs are the currency we work with. “What are we optimising for?” and “How can this go wrong?” are two of the best questions to be asking as you review design work. We are always optimising for something. There are always repercussions to changing a system. The work might look like building an app or website, but what we are really doing is intervening in a system. Start by asking these questions, put them in the project brief, and then check in on your view of the answers as changes to the system take effect.
Navigating trade-offs was also the theme of the talk I did with several colleagues at Services Week on Wednesday morning. We discussed the challenges of designing digital services for secondary care in the NHS and tried to unpack how the organisation’s structure, policies, and finances affect how we design and what we are able to produce. It was fun, and trying to keep it within 25 minutes made it an interesting editing challenge.
One of the concepts that I focussed on was the difference between the mental model most patients have of the NHS and how the system actually works. People believe the system is unified but it is actually highly fragmented. When our work involves stitching together bits of technology from a bunch of providers, we have a choice to make about our design approach:
- mask or fix the complexity so users don’t need to worry about how the system is constructed (these tasks might be radically different in scale)
- demonstrate how the system is constructed so users better grasp what they’re dealing with
Choosing between these approaches doesn’t always need to be binary, but it does require a considered opinion on both what is good for the individual and what is good for the wider public (i.e. society, civics). This is where “do the hard work to make it simple” might be misunderstood – is it good enough to make things appear to be simple, or do things need to actually be simple? One is tricky, the other is profound.
After the talk was over, from 9:30 Wednesday onward, it felt like a series of Fridays, but in a bad way. I was completely discombobulated and spent a lot of time trying to remember what I was supposed to be doing while feeling like I needed a nap. I think that my nervous system is a bit fried after all of the announcements last week. I’m hoping the next few weeks will involve fewer big announcements and more clarity on what will actually be happening to NHS England so that I can do more to help people find their footing. Right now, there is an absence of detail, and my sense is that a lot of people are filling it with speculation. This is natural enough, but it is also distracting and exhausting. We’re all going to be less productive until things become clear. I hope our leaders know this.
Some things I found on the internet:
- The reshaping of NHS national bodies has only just started. How will it finish? This is an excellent breakdown of the changes coming to NHS England from Siva Anandaciva at the King’s Fund, outlining what will be hard along with what probably hasn’t been considered yet.
- Login to a revolution. The DOGE analogy is gross, but this exploration of what the blueprint for digital government implies by James O’Malley offers some glimpses of the future.
- What a service is. New guidance in the Service Manual about how to define a service (obvs).
- Rewiring the state: Starmer takes on British Bureaucracy. Eliot Wilson on the recent announcements from government related to civil service reform, productivity, and technology.
- “Digital health records are critical to changing the NHS”. Charlotte Refsum on how centralised digital health records could improve healthcare in the UK. I am 100% for this.
- Vibe designing. Matt Jones on designing with AI. I think the “cajoling a colleague” part absolutely was the design process and the point!