Why Design Principles Are Reshaping Public Policy and Healthcare
Design is a rising fascination for policy makers, system designers and those at the coalface of care. Who would have thought principles of design would be influencing those outside of the creative arts sectors?
Dieter Rams popularised ten principles of good design. The heart of great design is elegance. To achieve that it must be simple yet thorough, balancing unobtrusiveness with usefulness and even beauty. It must be honest in avoiding false promises, environmentally sensitive, and still have room for good aesthetics. Most importantly, it must have timeless functionality which addresses all required details whilst fading into the background and allowing users to focus on the task at hand. Innovation which pushes boundaries and creates longevity must be balanced with avoiding fads and form over function. That is a tall order for people working in a system who want to get things done and enjoy doing it.
Why Design Thinking Matters: The Cost of Skipping the Process
What Happens When We Skip the Design Process
Design thinking is fundamental to good solutions because without it, unintended consequences occur. Spending time up front defining the problem, working up alternatives, choosing, testing, refining and then launching things which work is an entire project management discipline. In a busy world it is easy to jump from need to solution without thinking through the many elements of a good design, let alone the underpinnings of a design which will work for those involved in the system which results[1].
How COVID Exposed Hidden System Design
It is only when things shift rapidly that we expose the inherent design and the potential inadequacies and benefits of what we currently do. COVID changed the way we think about where work and services can occur, introducing freedoms around place we thought would take decades longer to achieve. Moving to a new location, service provider or program can expose assumptions and processes we once would not have questioned.
Choice Architecture in Everyday Life: A Tale of Two Bin Systems
Councils in Australia are tasked with delivering on the three “R’s”: roads, rates and rubbish. Roads and community infrastructure to make the region productive, connected and economically vibrant. Rates to pay for the services residents demand and good governance over those things they hold dear. Rubbish and other health-related services to keep the community safe from its own excesses.
In cities, rubbish trucks arrive, collect from various coloured bins different forms of debris, and take the offending waste matter to whichever mysterious end the system has in mind. Places where green waste is composted. Cavernous sheds where recycled materials are separated and sent for re-use. Tips where the accumulated remainder is dumped. It all happens out of sight and, for many, out of mind. That is why councils are frequently offering advice on what to put where and how to reduce every city’s mushrooming waste. They celebrate the wins but plan for the worst, which is a growing need for contaminated sites and expensive waste management.
Let’s take a look at a rural equivalent. What happens if no rubbish collection occurs to your farm or land holding? Suddenly waste is personal. Council might provide different bins for the collection of discrete waste types and a central location some distance away where the more offensive items can be dumped. However, the decisions about waste become personal because your time and labour are involved in shifting garbage in ways which may not occur in cities.
That can result in composting every bit of leaf and vegetable matter you generate on your own land — a win for the environment. You might be more likely to engage in composting because less rancid waste is an opportunity to spread out the number of visits you need to make to dump waste. It might also mean you make sure you eat all your leftovers, because waste protein does not feed the microbes composting your waste — it gives them bad indigestion. You are also more conscious of buying just the right amounts of fruit and vegetables, because citrus kills your composting agents and other fruits take so long to compost that flies and other vermin proliferate. Something best to avoid.
Anything paper is another opportunity to feed your compost cycle. A home shredder and more attention to packaging result in better and faster compost. Thicker cardboard becomes an ideal weed mat. Amazing how attractive time in the garden becomes if it takes just a few steps and minutes rather than the time involved in loading a trailer or truck and making a run to the tip.
Consumer choices increasingly become about longevity and minimalist packaging because nobody wants a weekly trip to the dump. The result is good for the environment. The driver is you owning the consequences of your waste stream. Things can also go badly under the same scenario. The temptation to hoard waste for too long between trips can increase rodent populations, creating other hazards. However, most people will be attentive, as rats and birds are likely to be problematic for the chickens you might keep to consume your kitchen scraps. The offer of occasional council pick-ups for larger items might mean everyone gets rid of build-up of junk, because land can be used for a more productive purpose than watching waste break down over the decades. Not an eyesore many want near where they live.
This is choice architecture in plain sight. Richard Thaler and Cass Sunstein argued that the way options are framed and arranged — the defaults, the visibility of consequences, the friction in front of each choice — quietly shapes behaviour even when people believe themselves to be acting freely. The city dweller and the farmer are not different sorts of people. They are responding to different architectures [2].
How Habits Compound: The System Behind Lasting Behaviour Change
This example shows that every system reinforces habits as much as achieves impact. The literature on habits shows that timely and direct consequences reinforce change. James Clear’s work, popularised through his book Atomic Habits, also notes that the results of habits compound. Small changes which build on each other and in the same direction lead to more positive change. This is the essence of transforming a life[3].
Clear builds on a longer tradition. Charles Duhigg, writing earlier, framed habit as a loop of cue, routine and reward — a structure that operates largely below conscious awareness and that good design either harnesses or fights [4].
Clear identifies three levels of habit:
- Goal-driven habits — behaviours aimed at achieving a particular goal. For example, eating less to lose weight by skipping afternoon tea and replacing it with a cup of tea.
- System-driven habits — these focus on the processes which underpin achieving your goal rather than the goal itself. This might involve exercising early morning to change your blood glucose and burn more fat, making subsequent eating changes both easier and more powerful. Learning about your biology and incorporating exercise which builds muscle has a multiplying effect on the sustainability of your weight loss journey.
- Identity-driven habits — these occur because they match our beliefs about who we are. If you decide you are a sporty Mum, or one who will inspire healthy living in your children, you will prioritise exercise and healthy eating. This identity will keep you focussed on weight maintenance activity as much as the routines you adopt.
The insight Clear provides is that changing our identity first is the lynchpin to driving better outcomes. Sadly, most people start with goal-driven habits. Without the reinforcement of a system you create around you, or the vigilance your values and identity offer to keep the system in place, habit change is very hard.
Designing Dependence: When Outputs Eclipse Outcomes
This is interesting for those designing systems. Many systems have, as an unintended consequence, the creation of dependence. They shape the identity of users as passive recipients or mere consumers. If you define your offering only in terms of how many folks use a service — the output — and not the outcome goal of what the service or product is supposed to achieve, you are more likely to define success in narrow terms which may be unproductive for users.
Sickness or Wellness? The Hidden Incentives in Healthcare Design
The Cardiologist’s Dilemma: Sickness Model vs Wellness Model
It can be easy to create dependence in systems. Let’s take healthcare. Cardiologists do years of training, open a private practice and start receiving patients. Having spent over a decade training and getting qualified, and more than a million dollars buying a private consulting suite, the incentive is to fill your hours with patients with varying forms of cardiovascular disease. You need the revenue to pay back student loans and build your business. If all you ever do is prescribe medication for the disease patients have, without offering lifestyle supports, patients will keep coming back for their scripts and even for their later procedures.
What happens if you create a model where patients cannot book with you until they have seen a dietician and an exercise physiologist, or perhaps a health coach? What happens if you see success not in patients seen and income billed, but as patients discharged back to their general practitioner for care, who have been given self-management skills and are on lower doses of drugs? What is the incentive to do this in our current system? It is limited. Doctors are trained to “diagnose and manage” health conditions. That is a sickness model. They are not trained — and often funding does not support — the preventative health interventions which add to wellness. Whilst most doctors would love to see less sick people in the population, their goal as business owners is to use their skills to generate the income and lifestyle they want. As Dan Ariely has shown across his work on predictably irrational decision-making, professionals respond to the incentives the system places in front of them, not the ones we wish were there. There is no incentive to get radical [5].
The Singapore Experiment: Redesigning Healthcare Incentives
How Singapore Redesigned the Health Actuary Model
Let’s look at a system which has been designed to force different questions, Singapore. It is far from a perfect democracy, with the one ruling party protecting its power for over sixty years. The People’s Action Party was first elected in 1959 and oversaw the return of what had been a British colony to local rule.
In designing a healthcare system, Singapore drew on its trading and entrepreneurship mentality rather than the NHS community service provision model which would have been easy to adopt given historic links. Rather than government being the health insurer providing the funds and services to its citizens, Singaporeans receive payments into their own personal health account. In effect, they become their own actuaries and have to manage their health risks. From their account they pay for health services. There is a safety net for dramatic health events like rare cancers and traumatic injuries, but the rest is within your remit to manage. What makes their system unique is that if you stay well and do not draw down all your health funds, you can distribute them to your family upon your death. This motivates Singaporeans to make healthy lifestyle choices to avoid the weight gain which might drive heart disease and diabetes.
No system is perfect. It could be said that the incentive to pass on wealth reduces the desire to spend funds on allied health and end-of-life supports which might make life more comfortable. In other systems, the lack of attachment to cost can drive families to demand all sorts of interventions right until the end of life, no matter the cost or likely benefit.
How to Diagnose the Design Flaws in Your Own System
If we accept that every system is designed perfectly to get the results it gets, what are the incentives in the system you are part of? Where are the flaws in design? Is it so complex that people who cannot fill out forms do not access the supports? Does it take so much time that those who are time-poor, or who get frustrated with waiting, withdraw? Do staff get so frustrated with the process that they create workarounds which reduce the impact of the service itself? There are so many ways the elegance of a design can be undermined. Even the lack of investment in the buildings and infrastructure can communicate to both staff and users the value of the service and who it is really designed for. Beauty and aesthetics are part of our products and services in so many ways we do not appreciate.
Finally, is your design timeless or attached to a fad from so many years ago it has lost its relevance? Many systems were designed before women returned to the workforce en masse, when housing was affordable, when only the minority of kids did post-school education, and octogenarians were a rarity. Changing demographics and an increased understanding of the intersectionality between context, cause and effect mean that the fundamentals behind our system design may be in need of deep review.
From Passive Recipient to Active Designer: Reclaiming Agency in System Design
This is where integration across sectors becomes powerful. If there is an incentive to merely shift the burden of cost or care to another part of the system, the drive to solve problems and offer better value to taxpayers is reduced. Australia has a scarily fragmented funding structure in healthcare, which means we not only have a largely privatised model, we also cost-shift between work funded by state governments and activity funded through Commonwealth coffers. This often leaves patients stuck in a system which does not work, or leaves them paying the real price.
Moving users from passive recipients to a new identity, and including them in system design, can help overcome these challenges. Perhaps you are a user or stakeholder passionate about reform. Rather than designing a system to meet individual goals, now might be the time to ask if the system is serving higher-order goals and creating agency, activation and outcomes. If it does not, look more deeply at the design flaw and see where the incentive lies to keep it running as it does. Once you understand who has what at stake across the system, you are far better placed to design improvements which deliver change.
Article References:
- Kahneman, D. (2011). Thinking, Fast and Slow. Farrar, Straus and Giroux. Kahneman describes this leap from need to solution as System 1 thinking — fast, intuitive and prone to bias — overriding the slower, deliberative System 2 work that careful design requires.
- Thaler, R. H. & Sunstein, C. R. (2008). Nudge: Improving Decisions About Health, Wealth, and Happiness. Yale University Press.
- Clear, J. (2018). Atomic Habits: Tiny Changes, Remarkable Results. Cornerstone Press.
- Duhigg, C. (2012). The Power of Habit: Why We Do What We Do in Life and Business. Random House.
- Ariely, D. (2008). Predictably Irrational: The Hidden Forces That Shape Our Decisions. HarperCollins. See also Ariely’s work on professional incentives in medicine and finance.
