Where’s our National Health Digital Service?

Technology is often seen as the solution, but so often it’s really just another huge problem.

I have the unfortunate task of visiting our local hospital King’s College more often than I’d like at the moment. Nothing too serious, my wife fell down a few stairs in the middle of the night and broke her ankle. She’s on the mend, thanks for asking.

The NHS is a phenomenal beast. Most of the time, you’re just along for the ride, “go to the X-Ray, then come back here, don’t go to the front desk, come straight to us” a nurse tells us, “have you been referred or are you a self referral?” asks the assistant at the desk, “you’re not on the list, sorry” says a nurse practitioner. You have to give yourself up to the system, let it carry you along it’s digestive system. You have to remind yourself not to second-guess or doubt the nurses and doctors because they trained a very long time to be able to treat you at this moment. But at a rough guess, I’d say pretty much 50% of the experience in a hospital is what John Seddon would term ‘failure demand’ of some sort, or what Bob Deming would have called rework. Everyone there is preoccupied with coping with the system.

When you succeed, you do so despite the technology, not because of it.

The NHS is one big edge case, it’s a system made entirely of edge cases. Everyone in there is an edge case, they are all outliers, nobody wants to be there. Yet the way the system works seems designed only really to handle cases perceived as ‘routine’. As an example, I had a letter with a barcode, which stated our appointment time. There’s a kiosk type of thing in the X-Ray place where you can go and scan your barcode and check yourself in, like you would in an airport. Except, there’s a friendly man who is assisting people. The friendly man is the interface for the machine, they don’t even let you see the machine’s face. The friendly man is the interface. It’s welcome assistance because when he scans the letter for me, the machine bleeps like it’s slightly miffed but it offers no real explanation. The friendly man explains that we’re two hours early for our appointment. I tell him that the consultant asked us to come at 8.30am not 10.30am so that she could see us first and my wife wouldn’t get barged about in the rush that happens around 10am. The consultant had improvised and created her own priority for her patients, except the formally procured system didn’t really allow for this. Why should it really? These kind of technical solutions have been purchased through a rigorous procurement system which doesn’t put patients first.

Another example, after we saw a nurse on our first visit, we were given an appointment card detailing the time and place, with a handy little map to show exactly where we needed to be. I was pleased that it had a map. Except, when, as instructed, I took the card to the reception (they didn’t explain why) they took the useful card away from me and replaced it with a less useful object- a piece of paper with the same information, except there was no map.

It’s relatively easy to write off the problems as simply a result of its vast complexity. But it’s obvious to see why the problems exist. They exist precisely because of technology.

You can see where the technology works and where it doesn’t. My experience of plaster casts was previously limited to what I’ve seen in Carry On movies. I thought it would take forever to set but it didn’t. They have an incredible synthetic product which behaves like a bandage, but once wet, it sets very hard, very quickly. Now that’s a technology solution that works. Also, the X-Rays are no longer plastic sheets, they are sent between departments as high-res images on the computer with something that looks a lot like email. Walking from department to department, the X-Ray results seem to follow us around in the cloud. And also, there’s clear wait times displayed everywhere, which seem pretty accurate. So it’s not all bad.

But the failures of the NHS aren’t just within our hospitals, the NHS is the National Health Service, not a collection of hospitals. You can see the failures of our system on the streets begging for change, shivering a pale- our systems are failing to pick up and treat mental health and addictions that lead to homelessness.

For NHS hospitals, most problems seem to come about because of the interfaces and IT systems put in place by a vast array of different providers, mostly fixes that fail, systems that don’t evolve towards their purpose.

When will the Department of Health conceive of a digital strategy as strong as that of the Government Digital Strategy? We need a set of principles for the National Health along the lines of those created for the Government Digital Service. We need a strategy that…

  • … puts patients before The Trust, for example by using Plain English, not the language of the system. I have no idea what a ‘self referral’ is.
  • … works iteratively by not procuring expensive and useless technology systems sold by the private sector which never improve and only get in the way of people doing the work they need to do.
  • … makes things open so that systems and departments can communicate together more effectively

Where’s our National Health Digital Service?

Purpose isn’t easy

Giving work a sense of purpose isn’t compulsory. It actually rarely happens because, fundamentally it’s really quite difficult. But if you can narrow the purpose of a project down the rewards are huge.

There’s a classic HBR article from Theodore Levvit where he asks the question ‘What business are you really in?’.

For example, Starbucks isn’t in the coffee business, it’s in the customer service business. Their purpose is to delight customers. Achieving their purpose rewards them with feedback in the form of increased working capital i.e. manna, bread, money, which oils the engine of purpose even more.

Another example; ‘SaaS isn’t about Technology, it’s about making customers more awesome’.

More and more often, organisations recognise that they exist in order to create more customers. So, why is it still so difficult to understand the purpose of work within an organisation that many businesses still put themselves before the customer?

It’s because they don’t have to.

The capital they gained when they used to care about customers is still swishing around for most managers to swim around and relax in.

Many organisations talk about the importance of their customers but so often, organisations don’t act like they care about customers.

Many large and successful organisations act like self-serving, private members clubs, building things they think might impress their close friends and family.

I think it comes down to the fact that giving customer what they need is essentially a strategy for growth. It’s not a strategy leadership within organisations use for coping and enjoying work. This is possibly why it’s such an attractive idea to startups and disruptive technologies and models. Most successful organisations are built based on the vision of one or more pioneering, hard working, driven individual, H. J. Heinz, Steve Jobbs- not built for the purpose of profit but built for the purpose of changing their world. Then, when they die, or they sell or they move on for whatever reason, the finance department get hold of it and it’s then about maintaining dominance or the status quo, coping with reality and eventually the principles that founded the organisation slip away. They don’t get thrown out in one day, they gradually get forgotten while the focus is drawn more towards profit and away from the purpose.

There’s a study that shows that people in a position of financial strain have higher cognitive load than those not under strain.

And there’s another study that shows how people in positions of power are less able to empathise with others.

Poverty is debilitating, but so is power.

Monument Valley

I, along with what seems like the entire Internet (or maybe just Twitter?) have fallen in love with a little character in a pointy white hat called Ida. The world she exists in is inspired by MC Escher (apparently)- “every level is meant to be a work of art”.  ustwo, like Mint Digital seem to be able to create not only the kinds of side projects that make people want to work there but which are commercially successful.

After leaving college, I would play games like Metal Gear Solid and Tenchu on the PlayStation for 8-12 hours straight. In about 2002, after I graduated and moved to London, my first proper job was making cheap, disposable, sub-300Kb Flash games for MiniClip and MINIWORLDGames. Mission:Mars for example, has apparently been played “over 100m times”. I have no idea why, it’s deeply tedious and each level is more disappointing than the last. That particular one took less than a week. And it shows, most games took little longer than 5 weeks. But it was a huge buzz to have people enjoy playing games that you’d toiled over, especially if they became popular. After a while though, I started building games for brands- wine labels, washing powder, newspapers, and the really interesting bit of game development disappeared for me. I ended up building gambling games for Coral and Eurobet and the purpose of making games evaporated altogether, for me anyway.

Since then I haven’t played games much at all, until my kids got really into playing games on the iPod, Wii and Xbox. Recently the extent of my enjoyment of games has been limited to a few hours on Mincraft with the kids, Words with Friends on the iPhone and then yesterday for just an hour, with Monument Valley.

I think Monument Valley was created for people like me; people who either have fallen out of love with games or maybe haven’t discovered their love of games yet. The game itself is just gorgeous, controlling Ida through the scenery is akin to watching a kitten slide and climb over and Anish Kapoor sculpture. The open storyline leaves a lot to your imagination and the slightness of peril and the friendship with Totem gives it a relentless optimism and charm. It seems that the only slightly negative comments it’s getting currently are from more serious gamers that expect all games to take about 30 hours to complete. But I love how short the game is, like a novella or a short story that just leaves you with a pleasing glow. And for less than the cost of a pint!

The thing I like most is that it makes me want to make something, it’s made me want to pick up the side projects that I’ve left languishing (not neglecting!). You can just tell the tireless tinkering that has gone into the creation of this game, that people have really cared about it’s outcome. Not just cared about it but loved it. It’s clearly the product of a process that includes love as well as purpose.

bandcamp.com/jobs

There is no Bandcamp office. Our small team is sprinkled throughout the world, with arms, cells, pods, what-have-you in San Francisco, Seattle, Melbourne, Montreal, Portland, Oxford, D.C., Raleigh, British Columbia and Bennington (which is in Vermont). We get together all day and night on irc, design and document everything in a wiki, do a short daily hangout that is exactly like the start of Hill Street Blues, and meet in person a few times a year for strategizing, working head-to-head and midnight microsynth jamming. If you do not have a strong social structure outside of work then employment at Bandcamp will likely lead to obesity, depression, and an early death. We’re hiring!

Sheering and Slippage in Big Orgs

John Willshire introduced me to Stuart Brand’s How Buildings Learn last week because it talks a bit about how buildings have different levels, which change at different speeds and it’s interesting how the web is another layer of a building.

Coincidentally, I came across the same point in Dan Hill’s  Dark Matter and Trojan Horses yesterday;

photo

This is useful not just for thinking about the nature of change of buildings but how change occurs in any system, such as a large organisation.

Large organisations change at different paces. The marketing department is usually faster to change because, quite frankly, talking is easier than doing. Or at least, it used to be.

It used to be that building products and services was difficult. But it’s not any more. Now it’s actually really very easy to make good stuff. It used to take a team of 6 designers and developers working for a year just to put together a website that would take a form input, do some calculations in a cgi bin and spit out a response. Now we can make working, usable software within hours or weeks. So, while cycle times for software development have reduced to 1-2 weeks, finance planning cycles are still happening once a year, marketing is still happening once a year, strategic reviews are happening once a year. So what we’re seeing now is this sheering and slippage happening in new places. This is why we’re seeing things like #noestimates, because all the teams that are delivering things in cycles are wondering why the rest of their businesses is still stuck on a different layer on a different cycles. And where there’s slippage and sheering, there’s friction and waste.

So if marketing is capable of the required pace and so is the making of software, then what’s the next level feeling the friction?

Rather than #noestimates, perhaps we should be training a new generation of Financial Directors in the ways of agility? What about procurement departments?

Facebook’s full-spectrum media play

So Facebook just bought Oculus Rift.

I interviewed many many UK teenagers in 2012 and 2013 about sport, life and technology on behalf of a client. Even then, none of them admitted to using Facebook any more, it was all Twitter and Instagram. Though I suspect they were still popping in to see old friends in the same way they were still popping in to see their nans on a Saturday afternoon to plunder her Quality Street. Since then a lot of clever media innovations have cropped up that teenagers have lapped up like Vine and Snapchat. ‘Facebook is dead‘ studies said, because their audience was ageing fast. But it seems now that all you need in order to stay young forever is access to massive reserves of capital. It makes me think that if Facebook’s model is to stay as an advertising platform, they are simply buying access to the eyes of the complete spectrum of internet society. Facebook.com is really the bottom of the barrel, the dregs of the internet the ‘1 weird tip that will make you thin’, WhatsApp perhaps offers something a little younger and more connected, while Oculus offers the absolute bleeding edge of interactive hardware. It’s akin to Google’s recent acquisition of Boston Dynamics and their work on driverless cars.

It makes me think that something huge that’s missing from Facebooks spectrum is a really popular video platform, it has nothing like that which might rival YouTube. I wonder if Facebook will buy Vimeo in the next year or so?

Words are design

There’s little surprise in the idea that a job description for a content designer at GDS would be well written. It’s matter-of-fact, it has clarity without over-simplification, it’s resigned without being obsequious and it manages to avoid being officious or patronising. It’s a language like that of pre-war, Reithian BBC- the voice of the establishment. Now that the BBC’s voice is that of impartiality and diversity, it feels that in our internet age, the words of GDS could become the voice of the establishment. It’s the kind of language that I would like the robots of the future to use. I want most of my communication with services to be utterly characterless. In fact, if I could just have a button on my browser that could ‘GDSify this’, I wouldn’t hesitate to use on most websites.

Content design isn’t a common job title. There isn’t a ready and able workforce of people already calling themselves Content Designers ready to take this work up. It’s a new role for linguists, designers, IAs, UX and CX folk, call them what you will, those people that still haven’t really found a role for themselves between strategy, planning, design and analysis. But the idea of someone actually taking the time to design (not just write) content is quite new. It’s not an opportunity for someone to express themselves creatively. It shows a serious belief in the structure of words and their absolutely inseparable purpose from the colours, fonts, layout and structure of pages on the internet that we use.

Another thing that jumps out at me about this description is the idea that design can be a framework for other design- there is a visual language of boxes and type sizes and colours and all that, but the words also need a standardised and structured and useful framework too.

Government is setting new standards of behaviour, like it probably should. The creation of public information isn’t an opportunity to emotionally engage with our audience. If only brands could understand that when someone takes the time to visit their website to read about their product, that’s often just what they want to do, they don’t want to bathe in adjectives that ‘emotionally resonate’, usually they’re after facts- they probably just want to find out if they contain wheat or where the stuff is made.

Agile as a mindset, not methodology

It feels like there’s a huge backlash against Agile with a capital A recently, or more accurately Agile as methodology, as opposed to agile/agility as a mindset.

One example is the talk of #noestimates. Which could be summed up in this statement from Neil Killick on the topic;

“I believe teams ought to commit at the outset to building and delivering the best possible product by a given date and/or for a given amount of money”

In principle I like the idea. Estimation causes massive uncertainty and anxiety for everyone involved.

But I think, as ever, it depends on the context, whether you’re a team working within a large organisation, a well-funded startup, a bootstrapped startup or working with a client within an agency setting. In any situation where there’s a team delivering working software that’s intended to achieve a certain purpose, that team needs to get paid (excluding that pro-bono work you did for your aunt last summer). And in order to pay the team, there needs to be some capital raised in order to pay them. In order to raise capital, certain emotional concessions need to be made to those raising the capital (or providing the capital). The capital may come from re-investment of excess profit, a line of credit, angel investment, savings, whatever, it’s good if you can give some kind of indication of, given the information you have available right now, what that party might get in exchange for that.

Given that my context is usually to work for clients within an agency, my preference is to have the team make very loose estimates and to work hard to let the client know that they may get more of the stories they’ve want for or they may get less, depending on how it goes. When you say these stories are about x points, you’re creating an anchoring effect. Providing you are doing regular estimates (more flow, less stock), you can move up or down from your initial estimate, ensuring that the client is aware of the movement. This way, it’s not so painful, the client has a good way of understanding that their capital investment is worth something from the beginning and your estimates can move somewhere towards reality as you go.

It’s difficult to say with a straight face to a client “We’ll deliver the best we can in the time we’ve got” and, I find, the rare occasions when you can say that is when you’ve worked with them for years and they trust that you’ll create something that achieves their intended purpose in the time they’ve given you. After all, if you as a client are prepared to go without an estimate, you’re essentially getting somewhere between 4% and 10% extra working software because of the time you’re saving by not estimating.

So, I think the key to making #noestimates work may lie in being able to convince a client that ‘you’ll get what you get within the time you’ve given us’. If you can trust us, then you’ll get more value out of us.

I really don’t know whether #noestimates can work or not. I am keen to try it, but I just can’t get over the idea that someone somewhere has to get a rough idea of what they are actually going to get before they invest in the building of the thing before they invest.