The sum of its parts?

I’ve just finished The Spirit Catches You and You Fall Down by Anne Fadiman (see: last week). I’d definitely recommend it if you’re interested in how culture frames our understanding of health or the relationship between migration and identity. Perhaps not coincidentally, it also touches on many ideas that are relevant to my work and design in general. (A little context: the book is about a Hmong family who were part of a wave of migration from Laos to California following the end of the Vietnam War.) From one of the latter chapters:

[…] the Lees’ perspective might have been as unfathomable to the doctors as the doctors’ perspective was to the Lees. Hmong culture, as Blia Yao Moua observed to me, is not Cartesian. Nothing could be more Cartesian than Western medicine. Trying to understand Lia and her family by reading her medical chart (something I spent hundreds of hours doing) was like deconstructing a love sonnet by reducing it to a series of syllogisms.

This is a bit like what trying to reconcile local and national health services feels like. On the one hand, different communities have different needs and healthcare workers tailor their approach to suit the context. On the other hand, national services require a large amount of standardisation if they are going to work for everyone. Throw markets and third-party services into the mix and you have a mess of competing worldviews. Ostensibly all of the parts are trying to accomplish the same thing (providing healthcare) but they each have their own way of looking at the world and approaching the problem. Thus far this situation has resulted in conflicting policies and priorities that bounce off one another. I’m hoping the much-trailed 10 Year Plan will change this in some fundamental way because most of the time it feels like we (the NHS App team) get caught in the middle and no one wins.

Some challenges this situation presents:

• There are a plethora of services that do nearly the same thing but use slightly different approaches. If a patient has access to more than one of them in the NHS App (which is not uncommon), it can cause confusion and frustration.
• Different parts of the healthcare system use different words for the same functions. In the course of trying to get care, the patient might be told three different names for the same digital service, which makes it hard for them to know what anyone is talking about or where to find what they need.
• Patients think of their health in narrative terms, but the data we have at our disposal is not organised this way. We leave it to the patient to connect the dots between unrelated data sets.

In each case, the patient loses. The individual elements that patients have access to are working as intended, but when you try to weave them together, things fall apart because they weren’t designed to be compatible. That’s a bit of a problem for us: our whole raison d’être is to bring all of the parts together! With a drive to move more healthcare into a community setting, I think this is going to become an even bigger part of what we need to do. My sense is that we need to adapt our approach so that the centre and local orgs work together in a different way. Everyone knows what a problem silos are; the task is to build a new structure without spilling their contents.

I also had some great conversations this week about relational services, the challenge of defining quality, why I am such a pedant and how that relates to typography, whether service design is real, and what is and is not a seam. More on all of those in due course.

Ralph’s most recent weeknote has an excellent list of “some universal consistencies about what people need when looking for support with their health”. This should be part of the NHS Service Manual.