Mike Gallagher

I write science fiction, and science fiction isn’t about the future. I don’t know any more about the future than you do, and very likely less.

— Ursula K. Le Guin, introduction to The Left Hand of Darkness, 1976

A few weeks ago, somewhere in the midst of explaining why a thing annoyed me so much, I started to understand a gap in how we work, and by “we” I mean NHS England or possibly just “The NHS”, full stop. It became clear that it was no one’s job to imagine the future.

Most of my work is practical. The focus is on things we can accomplish, ideally within the current financial year, that do not require first addressing dependencies that are outside of our control. Almost all of the topics in that category exist within the interface layer of the app. The work is meaningful and important, but it has limited reach. Most of the problems that would make a serious difference to health outcomes live outside of the app, in the wider system. Despite my official title being Lead Service Designer, the work is not service design. The work is bricolage. The work is making do and getting by. Fixating on anything else would be insane.

My day-to-day posture toward the work is, generally, defensive. I try to stop bad things from happening, to hold the shape of the larger endeavour together while an ever-growing number of teams tack things on. The goals are coherence and raising the floor for quality standards. It’s honourable and necessary, sure, but hardly exciting. It involves no projection. It posits no grand theories for what might be. We reflect the system rather than direct it.

It is thus more than a little surprising that I now find myself a few days into a piece of design strategy work that will, hopefully, help to establish permission and backing to go after the really hard, systemic challenges that constrain our ability to create a truly digital health system. Through some combination of being a nuisance with a list of complaints, writing the odd declaration or two, and good ol’ lucky timing, I’ve managed to insert myself into an ambitious effort to describe the big picture of where we should all be headed. It has been, shall we say, a gear shift.

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To get started, I’ve embarked on a round of interviews with my peers. These are fairly informal and relatively short; just enough research to get a feel for the shape and dimensions of their domains. In those conversations, I am trying to both extract their view of the problems to solve and make a case for my work, advocating for what I am doing as worthwhile. I’ve had a few different reactions, but I’ve been using an analogy to describe my orientation: design as science fiction.

Here, I’m thinking about what Isaac Asimov called “social science fiction”, which he poses against gadget and adventure stories (think: Ursula K. Le Guin’s The Dispossessed or Octavia Butler’s Parable of the Sower). In my formulation, design is a way of describing a world that does not yet exist but should, a world that involves meaningful change to socio-technical systems. The designer’s goal is to draw that imagined world closer to present-day reality. As in all of the science fiction that I’m interested in, technology is but a foil for telling a story about what could be different for people, social groups, politics, and institutions.

The failure mode of this work is a beautiful video or set of slides that describe the impossible. We might be painting a picture of a different world, but it does need to be achievable, if also a stretch. New technology or altered social situations become a lens through which you can examine the consequences of change. What was different about being sick in that world? Who had power in it? What became cheap that used to be expensive? What did people stop having to do?

Frederik Pohl (or maybe Isaac Asimov) put it very well:

A good science fiction story should be able to predict not the automobile but the traffic jam.

Science fiction is, in essence, a game of constraints. So is design. Both work with, establish, attempt to change, and ultimately obey rules. You change a rule and follow the consequences, wherever they go. You trace a consequence and then work out how to change the rule that produced it. Imagination is easy; the hard bit is consistency and follow-through. Working out what some change of technology does to clinical practice, hospital referrals, or people waiting for care is half the work. The other half is figuring out how to make it happen. The first half is systems analysis while the second is actual service design.

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Eventually this project will end and I will scooch on back to my normal role. Knowing that, I can’t help but think about how this way of conceptualising design practice might scale to the individual product teams who are working in the trenches to solve practical problems in the here and now. How do I embed a pragmatic dreamer’s sensibility into teams that need to ship working software? I don’t know yet. This place is a constraint machine and it is very easy to end up blinkered, without the ability to look beyond formulaic solutions. The question I wrestle with is how to help teams make constraints generative rather than purely limiting. Science fiction uses constraints to create new worlds. Often it feels like our constraints result in nothing but limits and frustration.

The difference is that novelists get to choose their constraints while we inherit ours. They are nearly infinite and no one really knows what they all are. Unnamed constraints stop feeling like a material to work with and start feeling like nature. This suggests that a decent output might not be a picture of the future, but rather a picture of today if things were just a little different. Something that might have already been if we had done the work to alter the plumbing years ago.

It surprises me sometimes that few teams propose big, radical ideas that would completely reshape the NHS App. For the most part, people ask if they can add their thing to ours. A simple addition; one more appendage. That leads to the most common debate around here: “Where should we place a link to this new thing?” The framing of the question is a problem. Maybe the problem.

The question sounds procedural, as if it were just one of the normal steps everyone must take when constructing a composite digital thing. Perhaps. But the mere question proscribes a whole set of possibilities. Our language points toward an answer before anyone has had a chance to consider new, more ambitious ideas. People speak of “jump-offs”, which is to say, links in a menu that load fully- or partially-independent services that are maintained by a team that sits outside of the official NHS App Programme. We’ve used the term as long as I’ve worked here and it derives from how we work with third-party services that sit outside of our control. The term implies that placement is the sole work that is needed. When we begin a conversation with a team by focussing on this alone, we have already lost.

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In the middle of this past week, the App’s UCD leads (Simon, Auriol, and me) convened a chat with our peers from across the various App-adjacent areas. The central theme that emerged from the discussion was how to work in a distributed way while simultaneously maintaining coherence. Across 120 minutes, most of the more specific topics we covered were things that Simon, Auriol, and myself had discussed in the past. One topic, however, surprised me: the need for a sharp framing narrative for what the design of the app was trying to accomplish, something designers can use to situate themselves, such that they can extend the mission without constantly checking in with us.

It had never occurred to me to write that down. Three and a half years of work, a design system, user experience principles, design histories, this blog, loads of new features and services, and somehow it had never crossed my mind that someone should articulate the high-level conceptual framing for how the design works. It would be something short, sharp, punchy, and opinionated. Something that draws boundaries. Something that helps people make decisions that are consistent with our overall intentions. A proposition. Without that, people reach for what they can find, and what they can find is “jump-offs”.

Our design principles provide a way to gauge quality, but they don’t tell you how the parts should relate to one another. A design system approaches the question from the bottom up. Styles, components, and patterns give you tools to build with, but seen from a slight remove, they are a vocabulary without a grammar. We lack a top-down description that could help all of the loosely-associated teams working on the app to push in the same direction.

Of course we have a vision statement and strategy documents, but they are abstract enough that teams need to work rather hard to figure out what to do with them. It is too easy to come to different conclusions about what “good” looks like. With all of the pressure to move fast and ship stuff, local incentives drive each team toward a local maximum very quickly. By articulating the over-arching design concept, we would bridge the notion of a health companion and the elements we use to assemble the details. “All of your health services in one place”; yes, but how?

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Test results are a good example of how this plays out. Right now, there are at least four ways a user can learn about test results: GP-ordered results are pulled via an API and surfaced as rendered app views; hospital results sit behind a web link – a jump-off; other secondary care results arrive as PDFs that land in the documents section; some results also generate messages that show up in the user’s inbox. This is all to say that things are organised by provenance, not by meaning. One type of thing, four ways it can show up, various attempts at coordination but no melding. When a new data source appears, the question is “where do I place this?”, when it should be “how do I incorporate this?” Without a clear distillation of the app’s design vision, teams can’t even think the right question. That’s on me.

My greatest worry is that the app remains a menu of disconnected records and services – that we never meld the pieces into holistically considered services, never achieve anything like art direction, never get past being a well-organised foyer. To a large degree, that is what the app is today, and every team acting reasonably within their own brief adds a little more to it without ever asking if or how they can reshape the whole. Entropic forces pull in the direction of least resistance, which is adding yet another link. This isn’t a new kind of problem. Better words might help. If the only available language describes the current implementation, the current implementation is the ceiling.

The size of it all carries us along
More equals better, it’s what we want

— “A New Kind of Water”, This Heat, 1981

Amazing how heat distends both matter and time. The whole week has been a fever dream. Apparently we had quarterly planning. That feels wrong. I had to re-look at my calendar to make sure I wasn’t hallucinating. Alas, yes, it was four days ago.

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I discovered that carbon steel – what train tracks are made out of – melts at approximately 1400°. I also discovered that 35° weather is enough to potentially break all of the train lines in this country. That seems like something to get on top of given, y’know, the atmosphere and melting ice caps and ocean currents and everything.

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Quarterly planning is normally an in-person affair, but due to the threat of all of the train tracks expanding and then buckling because it is a little hot outside, we moved things online. We were supposed to run the event in Leeds this time. Leeds is too far away from London to walk.

The event is less enjoyable when held this way. There isn’t as much serendipity and every discussion has to fit into a pre-planned 30-minute slot. It is incredible how the mere presence of a defined time slot in a calendar can dictate the length of a discussion. Words and walkthroughs expand or contract to fill the available space, as logged in Outlook. Time might be a flat circle or it might be a set of 15-minute triple-booked slots; depends who you ask (Matthew McConaughey or Microsoft Outlook, in this instance). I do not like this particular timeline we find ourselves in.

Planning events for the App are interesting because the App is also basically half the organisation at this point. Half of the organisation did not come to our planning event. That feels like it might become an issue, in time. There are plans afoot to institute a more devolved approach, to make it easier for a wider range of teams to do App things, but those plans are not yet complete or ratified. In the meantime, we continue working to join the dots and bridge the chasms and any number of other metaphors for trying to get a shed load of teams to work together without everything exploding.

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My hayfever has been horrible. I’ve been taking allergy medicine to ward off the sneezing and runny nose and itchy mouth (yes, really). The medicine works, but it also makes me feel balloon-headed, a little dissociative perhaps, and like I’m about to get the flu.

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I’m on a panel at a King’s Fund this coming week and I’ve been working on my talk for the start of the event. I won’t be using slides and it was only when I was several hours into working on what I’d say that I realised that I have never actually presented publicly without slides before. With slides, my approach is a bit collage-like, gathering materials and trying to find a nice set of juxtapositions. I shape and reshape the story to make the interplay of words and images work. The process is kind of squishy. Without an image track, it is just normal writing. Make an outline, flesh it out, say it out loud a few times to get the timing dialed in, done. Less of an exploration, more of a linear sequence.

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Not sure I’ve had more than two hours of uninterrupted sleep since last weekend because of how hot it has been. That might also be playing into my sense of time.

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There is a certain sense of incoming pressure with regard to more and more teams wanting to do App-y things. It is so difficult to keep track of everything. We’re not yet arranged into the right shape to handle this well. We’re moving in the right direction, and progress is being made, but we also need to clarify who is in charge of the wholeness of the thing.

The rest of my little UCD Ops gang are also concerned. There is too much happening and too much uncertainty about everything. In our normal catch-ups and on Slack, there is a general sense of exasperation at the sheer volume of coordination and project triage we need to keep on top of. We repurposed our normal retro and planning time to focus on gathering a list of all of the work we’re involved with and all of the things we’re worried about. Once it was all written down, it was apparent that there are many, many things to do. There is too much to deal with at the same time, but at least now we have the beginnings of a to-do list.

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Where are all of these flies coming from?

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I did a little show & tell about Quiver at the NHSE design huddle on Thursday. I had forgotten that I’d suggested the topic to the organisers a few months ago. I figured I would only need 10 minutes to do a walkthrough, but it turned into a 40-minute demo, somehow. There were some good, practical questions (Q: Could this eventually replace Mural? A: Not entirely, but for mapping and collaborating around said maps, I think it could) and others that were a little more what-even-is-work-today (Q: How much of this is you, and how much is the AI? A: Most of the code is AI, but the ideas are me). I was in the office because the office has air conditioning. Over the course of presenting the tool and its various aspects, I became progressively sweatier. I wondered if I was just nervous about presenting (which isn’t like me). Turns out the air conditioning in the office had just stopped working.

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Bless Lucy and Elliot for bringing everyone in my part of the office ice cream.

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Our work on the native replatforming is ticking along. We’ve started pulling apart our prototypes into the beginnings of a design system package and a prototype kit, feeling our way through it little by little. That and asking actual native developers how to do it.

While we make plans for native design systems, we still need to contend with the web side of things – the web app version of the NHS App isn’t going anywhere. It isn’t clear how we deal with the long tail of web elements that’ll need support for years to come. I’d like to divest ourselves of the web-based design system and upstream anything useful to the Service Manual team. We’ll see.

The organisation’s current stance on code repositories being public/private due to concerns about frontier AI models is becoming a frustrating blocker. I can’t show you all of my nice PRs right now because they are private.

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I worked from home on Friday. It was 34°. So: hot. But in the context of sitting outside, in the shade, reading under a tree, that heat is actually kind of nice. I mean, sure, it is a bit warmer than I’d choose if I had a say in the matter, but this is also just how hot summer is where I grew up. I’ve lived in the UK for 13 years, but this kind of heat still feels normal to me and it isn’t particularly challenging. If I had access to a beach, the weather would be great. After lunch, as soon as I was back to work: awful, miserable, oppressive, the worst. My sense of temperature, much like my sense of time, turns out to be rather subjective and context-dependent.

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I find thunderstorms somehow comforting. Pressure climbs until it must release – there is an electrostatic discharge, rumble and rain, and a drop in the heat, even if just temporarily. As a kid we learned how to calculate the distance of the storm. This was probably just a way to make us less scared, but it worked. It provides a means to put distance between yourself and the terror of uncontrollable forces, to take the measure of the material world and put it in order.

Planning is over, for now. We’ve got lists of issues to work through, in ranked order. That should help deal with whatever escalating pressure the org throws at us next. Things are ok and the temperature has come down a bit. It’ll come back; it always does.