Beyond the Pilot: Co-Design is the Foundation for Technology Development

There's a well-known place in healthcare innovation called the graveyard of failed pilot projects. It's filled with promising technologies that were brilliantly engineered and well-funded but failed to achieve widespread adoption in the real world.

The cause of death is rarely a technical bug. It's more often a human one.

The technology was designed for a group of users, but not with them. It solved a problem the engineers thought was important, but not the one that bothered a overworked busy nurse or frustrated a patient managing a chronic condition at home. This common failure stems from treating "user engagement" as a box-ticking exercise rather than the foundational thread woven through the entire development lifecycle.

The traditional approach to tech development, where a nearly finished product is put in front of users for feedback just before launch, is profoundly unsuited for the complexities of healthcare. It misses the crucial context of a chaotic hospital ward or a patient's home life. It imposes new processes that clash with familiar established workflows, it makes assumptions about the user's needs, their needs and their skills, creating friction and burden. Fundamentally it fails to build trust, making the technology feel like another top-down mandate to be resisted and avoided, not embraced. This approach leads to failed products; wasted investment and an erosion of trust.

There is a proven, structured alternative. The recently updated CeHRes 2.0 framework, detailed in the Journal of Medical Internet Research, provides a powerful playbook for developing health technology which weaves through a participatory and iterative process. It reframes development from a linear sprint to a continuous, collaborative cycle together with intended users.

The framework puts this into a structured rhythm of context → value → design → operationalisation → evaluation, repeated together with users in the room. If you're interested in health technology that addresses equity, safety, and achieves sustained adoption, this is how it's done.

1. Begin Where People Live

This first step is called Contextual Inquiry. It means deep immersion, mapping your current state, not just with clinicians, but with patients, with diverse communities, with interpreters, and carers. This involves establishing community groups that are representative of intended users.

Then, you go to where life happens: into homes, community centres, and faith spaces, to gather a clear picture of users needs, real-world barriers, concerns around safety and privacy. You build legitimacy and trust.

2. Turn Values into Measurable Goals

The next stage is value specification. With a rich, lived picture, you invite a range of stakeholders to define what good looks like. Abstract values like 'access' and 'trust' are translated into a handful of SMART objectives. This is where you make equity a core part of the specification. If a goal is to "reduce clinic no-shows," you agree on targets for specific subgroups upfront, such as people needing interpreters or those with limited mobile data plans.

3. Design with Users

The co-creation stage is where you establish a co-design team together with a range of stakeholders; community members, clinicians, and service leads, giving them veto power where designs clash with the values charter. You move from paper to interactive prototypes in short cycles. Crucially, you connect design to delivery early, noting potential exclusion points (like selfie ID checks or video-only instructions) and testing for what matters to your end users. You work to make participation easy, addressing language and literacy barriers for example, with visual aids and conducting sessions in first languages.

4. Plan for a Successful Rollout

Before going live, you build an implementation approach with intended users. This means designing in inclusion: budgeting for interpreters, device loans, and data vouchers. You recruit trusted community organisations as paid implementation partners to train and support users. Training is delivered in accessible formats. Readiness checks with go/no-go criteria agreed upon with community representatives, ensuring adoption is a relationship, not a cliff-edge to adoption.

5. Evaluate for Equity, Not Just Efficacy

When you study impact, equity is considered: did the technology reduce, maintain, or widen gaps? Consider how you will collect and stratify outcomes by factors such as language, disability, income, and other key factors. You pair log data with qualitative follow-ups to understand why patterns emerge. Evaluation becomes a loop, and early findings, inform further evaluation cycles. If equity thresholds aren't met, you adapt and redesign.

This push towards continuous is not new to the NHS. User-led improvement is also reflected in NHS policy and standards.

• The NHS Service Standard requires that clinical teams work to understand service users in the context of health services.
• The refreshed Accessible Information Standard requires organisations to consider how they communicate, making it a legal duty to identify and meet diverse needs.
• NICE's Evidence Standards Framework requires that technology suppliers can evidence clear economic and clinical value and effectiveness, real-world outcomes, and deployment considerations.

These are not separate hurdles. They are converging requirements that signal a direction of travel for the NHS to a far more systematic, user-centered approach. However useful individual standards are, they don't offer a unified operational approach to achieving them. Together these frameworks create a clear picture of what the NHS expects and increasingly NHS buyers and regulators will reward products that can demonstrate this. This type of participatory design in the future may no longer be choice; it will be a condition for entry. However the gap frequently remains in how to meet these interconnected requirements systematically.

This is where frameworks like CeHRes 2.0 will become essential, providing the practical, step-by-step methodology to build the evidence and meet accessibility requirements as an integral part of the technology development process, not as a separate compliance exercise.

If you're in the midst of technology transformation, make co-design the default and integral part of it. The technologies that will truly solve our healthcare challenges will be grown with the very people they are meant to serve, in a way that doesn't leave anyone behind.

You can find out more about the CeHRes Roadmap 2.0 here

• Kip, H., Beerlage-de Jong, N., van Gemert-Pijnen, L. J. E. W. C., & Kelders, S. M. (2025). The CeHRes Roadmap 2.0: Update of a Holistic Framework for Development, Implementation, and Evaluation of eHealth Technologies. Journal of Medical Internet Research.
• National Institute for Health and Care Excellence (NICE). (2022). Evidence standards framework for digital health technologies (ECD7).
• NHS England. (2025). Accessible Information Standard (DAPB1605).
• NHS. (2024). The NHS Service Standard. NHS Digital Service Manual.