Open Health
By Jennie Winhall
We are in a small terraced house, and Amy is showing us around her kitchen. She opens a cupboard at the back to reveal a second fridge full of re-used plastic bottles of water. “Now”, says Robin, “that is interesting. Here we have something”.
It is 2005 and we are in Bolton, looking at how people are living with diabetes. Amy, it turns out, feels constantly thirsty. There is little food in the house. Immediately drawn in by Robin’s obvious interest, she launches into her story, in which diabetes is a bit-part player in a cast of everyday struggles. We leave several hours later, with a strong sense that the health service as-is will have little impact on how Amy lives her life, but full of ideas about what might.
On the train back to London, considering an idea about ‘health miles’, I ask Robin an innocent question: how do alternative currencies work? By the time we arrive 3 hours later I have learnt about interest, depreciation, and the importance of circulation; about the success of Wörgl’s currency in 1930s Austria and the reaction of the threatened banks. I have begun to form a picture of the dynamic forces at play beneath the financial system, as seen through Robin’s eyes. And so has most of the carriage.
This is what it was like to work with Robin. As a young designer, I had never worked with an economist before: imagine my disappointment when I learned they weren’t all like him.
We began working together at the Design Council’s RED Unit, where our task was to bring to life the contribution design could make to re-conceiving the health system on distributed, person-centred lines. It was a real moment of possibility: Derek Wanless had just published his report on the threat to NHS finances posed by chronic health conditions, calling for ‘the full engagement of people in the maintenance of their own health’. I had worked with Hilary Cottam and Charlie Leadbeater on ‘Co-creating Health’, which drew on the new peer-to-peer technologies emerging at that time to envision a system based on principles of collaborative production. We partnered with innovative leaders in Bolton and in Kent to design and prototype the new kinds of services that such a health system might offer, with lifestyle changes around diabetes and exercise as our focus.
In the background to this work were several ideas that Robin was working with. Firstly, how to move beyond a model of ‘personalisation’ as the customised mass production of what is still a centrally determined product, to a model structured around the complexity of individual’s lives, that distributes to them the agency to create as well as to benefit from the resources needed for good health. Robin was looking at systems that thrived on participation rather than being swamped by it. Secondly, as people become producers rather than consumers, how to organise the new types of support they need. We were working with Jim Maxmin to explore his and Shoshana Zuboff’s ideas of ‘deep support’, where expertise, in the form of advisors or coaches, is on the side of people themselves. Robin was interested in what this could bring to the health service (and later our work on energy), what it meant for issues of trust, and whether it could apply to the collective, as well as the individual. Thirdly the problem of a preventative model, where there is no immediate need driving people to participate. Robin envisioned an ‘economy of motivation’ for active health, drawing a parallel with his knowledge of the ways in which environmental policy had created a climate that encouraged people, firms and local authorities to adopt sustainable living.
Through this work, we developed the idea of the platform, rather than the service, as the organising form. Instead of delivering a fixed service, you would set up an open-access platform, allowing people to draw down and configure whatever support, roles, tools and resources they needed to create healthier lifestyles. We called this ‘Open Health’. For Debbie in the Parkwood Estate in Kent, too afraid to join a gym in her 40s, this meant forming a walking group with her friends, and inviting in a coach to work with them to increase their activity levels. The measures of progress were meaningful to them, not to the health service. It was much more aspirational: “Ooh, Debbie’s got a coach!” in the words of Debbie’s neighbours.
The design work we were doing at that time was pioneering: staging live experiences with residents in Bolton and Kent to prototype these new services, taking part with them and improvising in real time based on their responses. Through this we learnt what it meant to design for an open-ended, evolving service, where people can shape both form and outcome, rather than for a linear and fixed one; which Robin saw as a key challenge of moving to a distributed model.
Robin wouldn’t have called himself a designer, but the interplay between the macro and micro, between abstract and concrete, were both key to the way Robin worked and an inherent part of design. He made us write to him each week with our reflections from the practical design work, and he would write back to us: it was a way of drawing on the micro insights to inform the macro thinking, and vice versa.
I always thought of Robin as a designer of systems. He understood so clearly both the technical and the cultural character of a system, from its operating philosophy to the economy underlying it. Re-reading ‘Open Health’, what strikes me most is the clarity of his thinking about what is needed: not only for the new model, but for the transition to it. The question of how to orchestrate these deep transitions is pressing today across many areas of life, and Robin’s writings give us a template for acting.
September 2020
Jenny Winhall and Robin Murray, with members of the Bolton Diabetes Centre (from Jennie Winhall & Colin Burns, The Diabetes Agenda, RED Design Notes 01, London, Design Council, 2006)