Hilary Cottam is the Founding Director of Participle, a social enterprise re-defining the role of design, providing systemic solutions to persistent problems of poverty and inequality and the 'new' problems resulting from changing demographics, new lifestyles and global resource constraints.
Previously, Hilary was a director of RED at the UK Design Council. Hilary's recent project work includes co-created preventative health services, a radical re-think of the prison system and a new approach to designing schools for the twenty-first century.
Hilary was named a Davos Young Global Leader in 2006 and UK Designer of the Year 2005 in recognition for her achievements in championing a more inspiring and efficient approach to public service innovation.
She is a founding director of the Do Tank Ltd and School Works Ltd (1998), a non-profit company that provides low-cost (or no-cost) solutions to enhance the environment of secondary schools.
Prior to returning to the UK in 1995, Hilary worked for the World Bank.
She holds a PhD in Social Sciences and was educated at Oxford, Sussex and the Open University.

A NEW VISION AT THE DESIGN COUNCIL

You were running a very interesting unit at the Design Council, called RED, up until last year. What was RED and how did it work?

We were trying to do two things. First, we were trying to bring design thinking to the transformation of public services: how to turn the traditional design spend in public services into an opportunity for excellent design. After all good design doesn’t cost any more and very often the public sector is not commissioning the best design. And second, we were looking at how design thinking and design techniques could help us to re-think the systems and the structures within public services, and possibly to re-design them from beginning to end. What we have done with health is a classic example. When the government looks at hospitals, it is often focused on things like reducing waiting lists. While this is important of course, we have to be aware that we are now in a situation where one in five Britons has a chronic disease. We have to put more emphasis on designing new services that engage with people’s behaviours, emotions and lifestyles and help them to either prevent the onset of a chronic disease, or at least to better manage that disease within their daily lives.


What do design processes and design thinking bring to that?

It is of course designing in a non-traditional way. The design outcome might be a service or some form of public good. What we were trying to do is bring our design thinking to bare on these problems by stretching the design industry itself, and push design methods by critically combining them with other disciplines in order to confront these big, global strategic issues.


Can you give us an example?

After Charles Leadbeater and I published a pamphlet on ‘co-creation’ which was our vision of future public services, we asked people to step forward who would like to pilot the approach. Kent, a local authority with some of the best public services in the UK, but also with pockets of quite entrenched poverty and deprivation — for instance, housing estates where people are now third generation unemployed — asked us how we could work with them to support those people to lead healthier lifestyles. They were very aware that otherwise these people’s chronic diseases would eventually end up becoming a big cost to both themselves and the state or the local authority. We also worked in Bolton which has one of the best diabetes networks in the UK, yet was unable to support behaviour change of people with diabetes.


A FOCUS ON DIABETES

What did you do concretely?

We looked at how we could develop small-scale systems that would both support people in their communities and lead to wider systemic change. In Bolton we came up with a simple solution that changed the nature of the interaction between the person with diabetes and the nurse, the frontline worker. This frees up quite a lot of resources in the service, thereby opening up opportunities to systemically redesign the service. We use design methods to start from the user perspective and to think about future public services, but we also worki with other disciplines, e.g. policy and economics which allows us to look strategically at what is already happening, where the incentives and the resource flows in the bigger system are, and how can we work with those to re-engineer a solution that can be scaled.


You mentioned the example of diabetes, how was that implemented?

We worked with what we call ‘extreme users’ - the hardest to reach, the ‘most difficult’ - in order to design the service around them. For example, in Bolton we took some of what the professionals thought were the most problematic cases. We went into their homes and really tried to understand them. We didn’t want to see them as people with problems or as diabetes patients, but just wanted to understand their wider lifestyle issues. We wanted to find out what the incentives and trigger points would be that would help get them started on a different path, towards a more healthy existence. Understanding those patterns across a small but very diverse range of extreme users helped us build an idea of how you could design a service that would transform this.


What was the main issue for you?

Nurses often run a questionnaire with diabetes patients. It is the same questionnaire every time you go. The patient learns to lie and the nurse learns just to tick the boxes and forget about it. The question is how to disrupt that relationship so there is a more honest interaction, without going through a huge change management process on either side. Once you manage to change that and the people with diabetes expose their real issues, then the question becomes how to support them through an often difficult to implement lifestyle change. After all, we all say “I’m going to the gym” and we never do it. None of us are different in that respect.


So what did you do?

What we developed was a simple pack of playing cards. The person with diabetes now goes to the consultation with their 52-card pack and take out one to four cards that represent best what they want to talk about. This has various effects. First of all the person already starts feeling confident. Instead of being told every week to stop smoking — which may be something they feel they can’t manage right now — they can now volunteer to start walking, or stop eating cake, or whatever it may be, and feel confident about that commitment, because they pick an issue they can do, then act upon it, and so go up a ladder of better behaviour patterns of more healthy lifestyle choices.


You also make it easier for people to talk about their problems that way.

80% of the time of any frontline worker in British public services, whether a prison worker, a school psychologist, or a nurse, is spent on diagnosis, leaving very little time for any actual support work. It was the same in this practice: running this questionnaire took 80% of the time. The diagnosis is now much quicker because the patients do it themselves. The patients come for consultation and present an issue that they feel confident about, and the nurse can take on a more traditional supportive “nurse” role, by saying for example: “OK, if this is the issue you want to tackle - think of how you might really do this”. The whole interaction becomes very different. Saving time also means that we now have more resources available. We set up a ‘Me 2’ service, where people can choose to work with a peer rather than with a nurse, because they may feel more comfortable with someone who is not a traditional health professional to support them through that lifestyle change.


TRANSFORMATION DESIGN

So this is what you call ‘transformation design’?

Transformation design is basically the methods that we use. We have written a little paper on the matter that includes the key issues. On the one hand there is the user-focus, and on the other the strategic level. Design uses a consultancy mode where you are given a brief or a problem and then you have to solve it. Often the problem we are given is just a symptom and the real problem turns out to be somewhere else. Interestingly, it is not just a different problem, but is sitting in a different institution: what they present as a housing problem, may be a health problem and so on. By putting together partnerships — we are not working as traditional consultants — we are able to work outside those silos.

Transformation design is a kind of catch-all for a very interdisciplinary way of working, because the projects and work we do could not be done by designers alone. We always have at least 3, usually 5 different disciplines in our team, of whom one or two members may have been trained as designers.


What makes it into a design approach then?

It is so partly because people have called me a designer, I am not a traditionally trained designer and I have no particular interest in it being called ‘design’. Having said that, there are some things that are particularly important about design that no other discipline brings, so I think that design is a critical part of the mix, but it is not the only thing.

What is critical is the visual nature of design. Also important is the fact that you can do deep work with potential users and engage with emotions and lifestyle issues.

Working with users in a visual way, enables us to engage outside their traditional responses. That way you are able to probe quite fast and much more deeply into people’s otherwise quite set responses to questions that they then are able to reflect upon in partnership with you, in a way they might not be able to if it was just a traditional interview or a focus group.

A visual language enables us to work across disciplines, involving e.g. a person with diabetes, a nurse, perhaps even a health minister on the team. Having a visual language means that traditional hierarchies can be put to the side because everybody is using new tools that they are not used to. There is a certain levelling in that process.

The other thing that is important is that we are not a think-tank: we are doing real projects, we are making a concrete difference on the ground for people in their everyday lives. So it is crucial to move the concepts very rapidly into action and that’s where a design process is valuable. Designers prototype: they mock up things very fast in real time. This is very different from the traditional piloting approach within the policy world, where you bring sense to something, you build a model in a very artificial environment which usually does not scale very satisfactorily. With a design approach, people can visualise what the solution is, get excited about it, and even prepare to commit resources to it, because there is a vision of what the difference might be. It is not a lifeless report on somebody’s desk.


CONFRONTING BUREAUCRACIES

But if you work with the National Health Service in the UK, or with the Italian health services for that matter, you are always dealing with a huge bureaucracy which is set up based on a paradigm that comes from having to heal people who have acute diseases and the methodology of the factory — the big hospital — to do so. It is not easy to make change in these systems, because the systems are so big and so powerful. How do you go about that?

Don’t tell me about it. Famously, the British NHS is bigger than the Russian Red Army. I think this is a problem that we are constantly grappling with.

One of the solutions is finding the leaders for change in those bureaucracies. The British government has over the last 10 years pumped a huge amount of extra financial resources into health and education with only marginal improvements in actual outputs. There has been a realisation that a lack of money is not necessarily the only problem, although obviously resources are an issue. But in most Western countries the levels of taxation are pretty much as high as any population is going to bare, so we are not going to be able to improve this through fiscal changes. We are going to have to rethink the systems themselves. This realisation has been one of the things that really supported our work. There is a new openness at the higher levels of bureaucracy to a very different way of doing things. And don’t forget that there is always openness at the frontline as long as you engage people in change. The best ideas we had have usually come from frontline workers. In traditional modes of institutional change, those people had change forced upon them, rather than allowing them to become architects of the change themselves.

The fact that we are working all the time with senior policy advisors within our central government, prevents us from taking an approach where we would be developing some bright new ideas on our own and then lobbying them, saying ‘hey, isn’t this a good idea’. Instead we are including [these people] on our teams, working alongside them, so they have ownership of that change.

One of the reasons that my colleagues from RED moved and formed Participle, our current organisation, was because we are very interested in how to scale this. Previously we worked with hundreds of families, or for example 20 schools and we now want to move to work with thousands of families and we knew that in order to do that we needed to start our projects in quite a different way, but we also need to get a different level of investment behind them so that our prototypes are already reaching many more people and we can have a longer run time with them with better testing, better metrics.

At the Design Council resources for measurement were limited, so a lot of stuff that we came up with was anecdotal which obviously doesn’t really help you to shift big systems and that is what we need to do.


IT’S A MATTER OF IMPACT

One of the examples that people have been looking at in the healthcare system is the SPARC Innovation Lab at the Mayo Clinic in Minnesota. It is a separate section within an existing hospital where they try out new things and prototype them until they get them right and then they roll them out in the hospital itself.

They have a similar approach to us in many ways. In our transformation design pamphlet we wrote about them as we think they are kindred spirits. I would be very interested in visiting them because one of the very early projects I did was a schools project. We were very successful in the context of that school — re-designing curricula, management structure, personnel care and also the building — and the school went from officially being a failing school to one of the top 20 most improved schools in the UK.

As a result a couple of things happened: government changed some aspects of how they were investing in school buildings, so some of the things we did at that school are now the norm for all schools. I also set up a social business called School Works which has since gone on to offer services to 19 other schools helping them on a similar process.

You could say that these are great result, with ‘School Works’ doing very important work offering services to schools, but how to go beyond these schools and impact the nation? We have looked at government to do this, but in the end it is the bit that didn’t really work and we didn’t get right. I would be very interested in knowing how SPARC is doing that: how to apply their lessons beyond SPARC, and affect the entire hospital structure, or even many hospitals by creating national change within the US. That’s what I think we are interested in.


I should interview them and let you know.

It would be fascinating to know how they are doing, because some of the things that work quite well for us also are extremely labour intensive: we have to build very good, strong relationships with government ministers and so on, and they are constantly changing. I think this is the same in Italy and in any large bureaucracy: you build a good relationship and then that person moves on. I have done a lot of work with prisons, we had 9 prison ministers in the last 3 years, so just as a prison minister gets briefed, is really supportive and is about to commission a new prison, they are moved on and you have to start all over again. So some of the methods we use that have been successful are also extremely expensive.


RETHINKING THE WELFARE STATE

What are you doing now with Participle?

Participle stands for ‘participation’. We are building on the work we did at RED. The RED team is all part of Participle plus some new people.

One of the critical things is about being able up scale up, and this is where Participle is different. We have structured ourselves in a way that we could get proper investments behind us so that we could work at a different scale, and this is all based upon a critique of our work at RED.

Over the last 10 years we have always been working at trying to reform existing institutions and moving them closer to people’s real needs. What dawned on me through my work at RED was that is very hard to do the radical innovation. You can incrementally innovate that way, but it is very hard to do the radical innovation that is needed. What you really need to do is to invert the telescope, start from people’s needs and think about how to wrap new institutions or reconfigure institutions and services around people’s needs.

So in the case of health, you don’t need to reform the health service. Instead you need to start from the assumption that most of the population has or will have a chronic disease and then figure out the sort of services you would wrap around people with chronic diseases. Only then you can apply the lessons to existing institutions, which often need not just reform but full reconfiguration in order to really reach people. We need to rethink Beveridge. The Beveridge report started the welfare state in the UK. There was consensus both on the left and the right that the UK needed a set of welfare institutions, and we still have those institutions.


When was this?

The Beveridge report was published in 1942, during the war. After the war, there was a complete consensus in Britain that this was what had to happen, and it didn’t matter whether we had had a Labour or a Conservative government. There was commitment on both sides to implement it.

We are now at an equally interesting historical junction because both left and right realise that the institutions are bankrupt and that in order to address the biggest social problems we face at the moment we need to change behaviours. And this applies to ageing, to chronic diseases, and to the environment. These are all issues that affect people’s lifestyle. You can’t just patch up a service like the old fashioned welfare state did and hope that you can do it more efficiently. We are only going to change our CO2 emissions or our attitude to diabetes, if we join together and implement a lifestyle change ourselves. You need very different support systems and institutions to help individuals and communities do that.


THREE BIG ISSUES

And that’s what Participle is about…

What we are trying to do is to imagine what these new institutions would look like, given that the needs they are based on have changed so much. Over the next five years we will pick three big issues that are clearly massive, that everybody recognises as very big and that can’t be solved by existing institutions.

The first one is ageing because everybody knows there is a time bomb. Existing services come to you when you have physical failings: when you fall over, you break your hip, you can’t live in your home anymore, so they come when people are already in quite acute situations and they are increasingly rationed because more of us are growing old and there is not enough to go around.

What would happen if you saw ageing as a kind of possible benefit, a positive contribution, with lots of quite healthy older people around, rather than a drain on society? If you start from that mindset, you could think about providing services to support people socially and emotionally, rather than being focussed on their physical decline.

We have put together a partnership between the public and private sectors. We raised one and a half million pounds from the private sector, central and local government and are now working as a collaborative team. We are training people from each of those partnering institutions in transformation design methods and over the course of 18 months we will be collaborating in designing new types of services, getting them up and running, scaling them, and rolling them out across one whole local authority. The UK’s national government is also investing in this, because they are looking at it as a pilot for a nation-changing project.


This project was just launched?

Yes, at the end of September. This is something I have only been able to do now. I was never able to leverage that much funding out of the private sector while working for government institutions such as the Design Council. It has given us a completely different scope in what we can do and the way we can work.


Where is it in London?

In Southwark, it is a fairly central London local authority with high levels of deprivation.


What will the project be focussed on?

It is very early still. So far what we have started training a team from our partner organisations. One of the things we are looking at and we are testing through this project is how can we actually give our way to our transformation design methods to a much wider population. I am constantly struck by how many good ideas there are but how difficult, how little methodology there is for moving these good ideas through bureaucracies and into practice. I am not saying that the methods we have developed are the only way to do this, but I do think that they are very simple, practical and hands-on, so one of the things that we want to do is experimenting in giving away those methods.

We have also been doing a first round of user research and it highlights some major issues related to ageing. For example, migration patterns over the last few years, mean that most people have elderly parents that live at some distance, and this is true across the nation and across classes. So people need a different way of supporting their parents across distance. We are also looking at issues of bereavement and what constitutes a good death in a highly capitalist, secular society that doesn’t have good support services. We are looking at people that we can predict will have quite acute health problems and how we can work with them from a much more preventive end in an intense supportive relationship. We are looking at what employment means in later life, and the idea of ‘elderpreneurship’, as we call it. These are some of the strands, but it’s very early days and it is highly collaborative, so we obviously have no idea what the outcomes will be at this stage.


What are the other two major issues we will be focussing on?

We are in the process of identifying what the third will be. The second one will probably be something in the area of youth. Our working hypothesis is that future public services will not be organised around silos of health education, but around life stages: youth, ageing. I don’t think that it is how it probably will be in the end, but we need a working hypothesis that is different from the institutional set-up to give us room to experiment and a different perspective.



CREATING BREAKTHROUGHS

What advice would you give to an Italian public authority that is interested in innovation and in creating a more patient-centred hospital service?

I think that there are a couple of things that people can do. Mixing up disciplines can have very profound effects and is quite simple to do. When I used to work for the World Bank, I was involved with a very large, multimillion dollar community water credit project. We told local governments that when their water engineers go into a community, they must take somebody along who is trained in the social sciences and work as a team. This very simple practice of just making sure that those two people always went out together meant that very different conversations happened at the community level. The result was a very different structure of water credit and water planning for an entire country actually.

A different thinking will occur and a different vision will arise when two really different disciplines are brought together in a project. So I think that public authorities could start by setting up these unusual multi-disciplinary twinnings in every conversation they have. I am sure it would lead to some surprising and profound changes and would cost hardly anything.

What is really critical is to always do top down and bottom up at the same time. User-focus is great, but at the same time you also have to do some serious mapping about where your resources are going and how to incentivise your senior managers, because if those structures aren’t changing at the same time, your user-focus is not going to take you anywhere.

Another important thing would be to set aside 1% of the capital resources available for the planning and construction of major projects such as schools and hospitals for a well designed user process, as this will always yield better results, turning infrastructure projects into long term social investments.