NHS Citizen Design

Categoty: NHS citizenI’ve been having increasing difficulty making sense of the NHS Citizen project as I’ve followed it over the last year and a half, and I’ve been putting off reviewing the enormous and labyrinthine “microsite” that it has published to mark the end of its design phase. So today I’m just going to jump in and see what thoughts occur.

But first, as it seems a bit chilly here this morning I must put off the review just a while more in order to work some magic.

Is it really so chilly? On a bookshelf here in my home I have a little gizmo, a digital thermometer. It’s reading 18°C. That reading is a formal description of the temperature in the room.

Now, this particular gizmo is a bit special. I can press a button and the reading goes up to 19°C, and press it again so that the reading is now 20°C. I’ve changed the formal description so that it’s now false. Why would I do that? The room is just as chilly.

Here’s the magic. Over the next few minutes the room starts to get warmer. It continues until the room temperature really is 20°C. The gizmo’s formal description of the temperature governs the real-world temperature in the room.

It isn’t really magic, of course. The gizmo contains a radio transmitter that signals a boiler in the attic, which pumps hot water down to radiators in the room. It just seems like magic.

If you try this with the weather outside it won’t work. For example, I might go out in the rain one morning and buy a newspaper from the village post office. In the paper I might read that it’s going to be wet all day. The printed forecast is a formal description of the weather.

I could take a pen and scribble out the word “wet”, replacing it with “dry”. That would make the formal description false. But it wouldn’t make the real-world weather dry. To imagine that it could would just be magical thinking.

Later in the day the rain might indeed stop, showing that the forecast was wrong. But even that wouldn’t mean that my scribbling caused the rain to stop. There’s no such thing as magic even though it sometimes appears that there is.

Anyway, enough of that. Now that it’s not so chilly, on to the review of the NHS Citizen Design.


Citizenship, it now turns out, is at the heart of the NHS Citizen project. It wasn’t always this way. In a paper describing the project published in October 2013 the word “citizenship” doesn’t occur anywhere. But now it does. Things have moved on.

If you navigate through the labyrinth from the front page to Research and Evidence, and then to Culture change and citizenship, and then to Literature review of citizenship in healthcare, and then download the 40-page paper Citizenship in the NHS- Literature Review, and go to page 3, the second sentence in the Introduction spills the beans. It says:

“Citizenship is the key political concept that governs the relationship between the individual and the state.”

There you have it. The political concept, which is a formal description, governs the real world. Magical thinking.

NHS Citizen’s core problem is that there’s no machinery in the attic that it can send a radio signal to so that its formal descriptions of how it wants the world to be can be made to happen in the real world. Pretty much all it’s done is spend a year and a half writing ever more complex and fantastic formal descriptions — a costly exercise in scribbling over the NHS weather forecast. I think that’s why I’ve been having increasing difficulty making sense of it.


Here’s another scribbling from the section, What is NHS Citizen?, also buried a few layers deep:

“The NHS belongs to everybody, but while there are many opportunities to be involved as a patient, there are too few opportunities to be involved as a citizen and owner of the NHS.”

I have two long-term medical conditions, but as far as I can tell they provide me no opportunities at all to be involved as a patient. Yet I have so many opportunities to be involved as a citizen that I have to pick and choose carefully between them in order to have time left over to do the shopping.

The NHS doesn’t, in any formal or meaningful sense, belong to everybody, either. What could we do, sell it?

The quoted statement is false both in respect of ownership and opportunities to be involved. It’s a deliberately false description offered up as a kind of prayer to some imaginary machinery in the attic.

The implication is that the project team wishes the NHS did belong to everybody, whatever that means, and that by stating that it already does it thinks the wish will come true. I have no idea what is really envisaged. The system we have now is that the NHS is owned by the state on our behalf, and its management is directed by the government we elect. What new system is being wished for here? I can’t tell.

And the implication is that the project team wishes for patients to be involved even less than we are now. It’s as if, for example, they think people like me with heart disease have too much say in the management of our condition (even though in reality we have almost no say), and that in future the management of heart disease should largely be determined by a general consensus on Twitter.

I worried over this interpretation until I saw it confirmed in a blog post by a member of the team, who confesses quite explicitly:

“For me, citizen-centred or civic architecture is all about the idea that technology could be designed with the citizen at the centre rather than the customer or consumer.”

Although I understand that the subject of that post was a different one, there’s a common underlying way of thinking, which is that having a life-threatening medical condition that forces you to be a customer or consumer of healthcare shouldn’t privilege you over someone who has only a trivial condition, or someone who is perfectly healthy.



I’m not convinced that it’s worth saying anything else at this stage. Like reviewing an enormous and labyrinthine mathematical thesis whose logical starting point, buried layers deep, is the premise that 1 +1 = 3, all the rest is either false or true only by accident.

Theoretically, NHS Citizen could now start building machinery, but that’s just theoretically. You might as well say that, theoretically, I could build machinery that reads my scribbling on the newspaper and changes the weather accordingly. NHS Citizen’s complex and fantastic formal descriptions would require machinery that changes the whole of society including all of its subcultures, including the subcultures of government and the NHS. Theoretically is the wrong word. There’s no theory for that. It’s delusional.

What next?

So what will happen next? I think it’s unlikely that the NHS England Board will become delusional too. On the other hand, it’s equally unlikely that they’ll admit to the cringe-making failure of the project so far and openly start again with a more practical approach.

My guess is that the Board will force the project to start building machinery, but it will be machinery that only does the things that are doable, the same things that were doable eighteen months ago. The design that is described in the “microsite” will be quietly forgotten as a kind of bad dream. Some of the things it claims about the NHS Citizen will turn out to be true by accident, but no one can predict which things they’ll be. It all remains to be seen.

Just over a year ago I wrote about NHS Citizen:

“I’m still not quite sure where its development is heading or where it will end up.”

That hasn’t changed, and reading that old post again I’m struck by how little has.


About Rod

Chairman of the Gloucestershire charity Suicide Crisis, Vice Chair of Relate Gloucestershire & Swindon, and an enthusiast for public involvement in the NHS.
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One Response to NHS Citizen Design

  1. Rod says:

    Post script: I wrote this in April and, for reasons I can’t remember, didn’t publish it. Then, in July, I came across it and pressed the Publish button.

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