Change NHS

The NHS 10-Year Health Plan provides a pivotal opportunity to reshape health and care delivery by embracing an engineering systems approach for the transformation and improvement of our health and care system. To be successful in ‘fixing the NHS’ the Plan must look beyond the boundaries of the NHS in isolation. We must simultaneously examine the social care system, public health policies, and the outcomes that the public want.  

To be able to innovate effectively we need to understand the behaviour of the whole health and care system: considering individual services, the interfaces between them, the physical and data infrastructure, the needs of users and staff, and the emergent behaviour of the whole – that is, we need to take a systems approach. Systems thinking allows us to identify the right problems to solve, to find the key leverage points for change, and to establish the governance needed to make meaningful improvements for measurably better patient and societal outcomes.  

New technologies such as AI hold transformative potential in healthcare, however, care must be taken to identify where these new tools are the right solutions, and in these cases, they need to be developed, deployed and used in a responsible way, supported by the right infrastructure and training. 

Fellows of the Academy have worked with clinicians and other experts to develop Engineering Better Care, a systems approach to health and care design and continuous improvement. This report provides a question-based framework to support transformation teams with understanding the system, identifying and managing risks, and designing solutions that will work for people. Supporting toolkits and training have been developed and are being piloted in numerous projects by Professor John Clarkson FREng, Director of the Cambridge Engineering Design Centre and Co-Director of Cambridge Public Health. 

The three shifts within this consultation all represent systems-related challenges, working across service boundaries for the benefit of the patient and the health and care system. All will require system-wide teams and authority - systems leadership - to identify opportunities for change and deliver real improvement despite the presence of antagonistic funding models. Integrated Care Boards have a pivotal role to play in enabling such leadership, not only in identifying and developing systems leaders, but also in ensuring they are given both responsibility and authority to deliver change. 

In health and social care there are multiple ongoing national and local initiatives to transform the provision of social care, shifting care from hospitals towards communities, introducing new technologies, and addressing the causes of ill health. Systems thinking tells us that ‘quick-fixes’ and isolated improvement efforts will not address the fundamental challenges of join-up across a complex system. However, there is currently no function in England that has the capacity, responsibility or expertise to understand the behaviour of local or regional health and social care systems, or to support the joined-up delivery of radical and effective improvement. 

The Academy sees an opportunity to establish a Centre for Systems Innovation in Health and Social Care, building on recommendations from the 2021 Council for Science and Technology (CST) report, Harnessing Technology for the Long-Term Sustainability of the UK’s Healthcare System. The Centre can support local Integrated Care Systems or equivalent structures with the systems and delivery expertise to identify, co-design, iterate, implement and evaluate effective solutions needed for transformation at scale. The Centre is predicated on the need for a health and social care system that delivers for patients and staff – with a focus on prevention, short waiting lists, brief hospital stays, and care provided in the community, supported by the safe use of new technologies such as AI. This Centre would stimulate transformative action with its systems expertise, would actively support local transformation initiatives, build capability in the workforce, and share knowledge and practice across the UK for the benefit of all. 

Challenges:  Risk aversion, antagonistic processes and a lack of oversight. 

Enablers: Adopting a systems approach, appropriate oversight and governance models, and proactive risk management. 

In moving more care from hospitals to communities, and delivering more services locally, effective interfaces and integrated information flows between multiple services are critical for success. Insights from the current behaviour of these interfaces highlight the challenges that will be increasingly faced as social care becomes more decentralised. 

In 2022, the Department of Health and Social Care asked the Royal Academy of Engineering to use its expertise in systems thinking to examine challenges related to delayed discharge of patients from hospital into community care. Through a series of interviews with staff at Kettering General Hospital and Royal Cornwall Hospitals NHS Trust, we mapped patient flows and key decision points within and between different hospital and community services, to capture their behaviour in practice. We brought those insights together in a rich picture to communicate some of these complexities. With insight from an engineering systems approach we identified three overarching challenges:  

An aversion to risk 

Risk-averse behaviour was seen as necessary by a wide range of service providers who are operating under varying objectives and policies to guard their limited local resources or to protect their liabilities, but this behaviour inevitably created bottlenecks. This manifested in practice as: care pathways operating as step-by-step processes, with lengthy planning for discharge not commencing until patients were ‘medically optimised’ leading to long delays and patient deterioration; community care packages being forfeited on readmission to hospital so that care providers could reallocate their resource, but sending patients to the back of the care queue; frequent incidents where outpatient transport ambulances were turned away at the doors of care homes; morning ward rounds seeing ‘ready to discharge’ patients last, limiting the time available to action the patient’s discharge that day. 

Antagonistic processes

 Local resource constraints and efficiency drives put different services in competition and conflict, often over limited resources such as community beds, with each striving to meet its immediate needs. Staff are sometimes tasked with processes which are inadvertently antagonistic to other parts of the system or to the patient’s objectives and needs. This manifested as: one hospital’s ‘no choice’ policy of discharging patients to the first available community bed within the county, no matter the distance to their home, creating knock-on problems for families and care providers who were unable to visit or assess the patient due to distance; recovering patients being moved between wards to take advantage of space, causing challenges for continuity of care and recovery, and for community providers to be able to locate and assess patients for discharge. 

A lack of oversight

No single entity or individual had responsibility for understanding how different services join up across the local system, how capacities of different services match, the range of complex patient pathways through the system, or to ensure that different services work together effectively. This results in mismatched capacity between acute and community beds commissioned separately by local councils and NHS trusts, and inefficient and ineffective information exchange mechanisms between community and acute providers.  

These challenges, and the complexity of the system, make it difficult to implement holistic changes which move care away from hospitals and into the community for better patient outcomes. Governance structures need to incentivise and enable decision-takers to seek the optimum outcome for the system, not the best output for their service. The Royal Academy of Engineering advocates for integrating a systems approach that encompasses people, processes, technology, and risk, to allow healthcare leaders to proactively identify challenges and optimise the system to meet its desired outcomes.  

This could be enabled through the appointment of Systems Leaders to Integrated Care Boards who would have the responsibility and authority to oversee and manage the interfaces between different health and care services. Integrated Care Boards, or equivalent structures, could be further supported through the establishment of a Centre for Systems Innovation in Health and Social Care. This Centre would have the expertise and capability to support drive the adoption of better ways to deliver radical and effective systems improvement. These enablers are expanded upon in question 5. 

Challenges: Outdated IT resources including essential equipment, lack of coordination, insufficient regulatory frameworks, and concerns over disruption hinder the rapid adoption of technology. 

Enablers: Improved digital infrastructure that allows for integration, trust-building for AI, systems approach with phased adoption, proactive risk management. 

The NHS lacks up to date and modern IT resources to support integration of new technologies quickly and the supporting digital skills. In the health sector there can be a lack of a coordinated approach to technology deployment that would allow for real world testing and refinement before full implementation.  

Innovators from the Academy’s Enterprise Hub highlight that working with the NHS can be a real challenge. While the NHS does a good job proving and demonstrating technologies, implementing new technologies across the NHS remains a challenge in part due to complexities with procurement. 

Data standards, secure storage and trusted mechanisms for sharing data are crucial elements of digital infrastructure for the development of data driven technologies in the healthcare sector. This data is sensitive, often low quality and not representative of the whole population. To capitalise on data, it needs to be findable, accessible, interoperable and reusable (FAIR) in order to support the development of these technologies. The NHS must learn from existing initiatives on enabling the secure and safe use of health data for patient benefit, such as Health Data Research UK. 

AI holds transformative potential in healthcare, offering new ways to enhance patient outcomes, streamline processes, and improve decision-making across the system. Our 2023 FORUM workshop with the Academy for Medical Sciences on "Accelerating Effective and Safe Adoption of Artificial Intelligence in the Healthcare System" highlighted that confidence among healthcare practitioners and patients remains low, partly due to concerns over data privacy and cybersecurity, as well as unclear accountability structures. To address this, the workshop highlighted the need to build a trusted regulatory framework, this must be supported by robust methods of verification and validation. It called for enhancements to the digital infrastructure, development of high-quality datasets that are standardised for interoperability and ensuring healthcare providers have the training and resources necessary to adopt AI safely. Also, early engagement with end-users can foster trust and make AI technologies more relevant and effective within diverse clinical settings. 

While it is important to have robust regulation to ensure patient safety, current regulatory frameworks can prove challenging for innovators to navigate, which can result in potential benefits not being realised by the patient or the wider economy. The newly created Regulatory Innovation Office (RIO) in the Department for Science, Innovation and Technology aims to support the healthcare sector to deploy Artificial intelligence (AI) innovations safely, improving NHS efficiency and patients’ health outcomes. The RIO should enable opportunities for greater collaboration and learning from other sectors, and offer training for regulators to understand the opportunities and risks of technology advancements.  

The Academy is delivering a series of People's AI Stewardship Summits to embed public listening in our innovation accelerator. In cities across the UK, we invite members of the public to share their hopes and fears for AI and to reflect on how AI could be developed to benefit local communities, while local innovators listen and respond to the public's ideas. In both Glasgow and Belfast, people were excited by the opportunities for AI to increase accessibility of care, create faster and more accurate diagnosis, and AI collaborating with healthcare professionals. Further public consultation is required to understand public concerns and gain trust as technologies are developed and deployed to deliver healthcare. 

There is a shortage of clinicians and care providers across the health and social care sector who are confident working with software-based systems and who can effectively work with systems that offer decision-support. Staff will need these skills for widespread technology adoption. The Topol Review identified the need to develop a greater awareness of the required capability, provide access to training, and deliver the skills needed for patients and citizens. It would also be useful to identify champions within hospitals to help provide practical guidance and best practice of using software-based systems. 

A systems approach enables phased technology adoption in healthcare, using testing and prototyping to address real-world barriers and adapt any solutions within the broader health ecosystem. Proactive risk management, simulation, and modelling can also help healthcare providers address challenges early, improving technology integration, reliability, and patient outcomes while enabling sustainable digital transformation. 

Challenges: Disjointed healthcare systems and poor data sharing and technology implementation hinder early illness detection. Inadequate infection resilience and indoor environmental quality in public and private spaces are a less well-recognised factor in increased health risks. 

Enablers: A unified, people-centred systems approach, coupled with infection-resilient building standards and improved indoor environmental quality, can drive proactive, preventative health measures both in healthcare and public environments. 

Currently, healthcare providers often operate in silos, making it difficult to establish a comprehensive view of patient health across all services. This disjointed structure hinders the ability to detect early signs of illness, as patient data is rarely shared across the full system of care.  A lack of coordinated, system-wide initiatives limits proactive, preventative care and keeps health services reactive. A person-centred systems approach could improve early illness detection by enabling data-sharing and unified care pathways across services, identifying and addressing health risks sooner. 

There is strong support for specific and early diagnostic technologies, like AI for cancer screening, yet adoption remains slow due to systemic resistance and regulatory obstacles. Innovations like blood tests for multiple cancers show promise, but delays in implementation limit their impact. Another example is technology for the early detection of dementia which is currently at trial stage. For this new technology to add value to patient outcomes there would need to be an effective redesign of the dementia care pathway as opposed to the new technology being an addition to an existing pathway: the redesign of pathways would benefit from a systems approach and co-design with all key health and care stakeholders.  

An engineering approach emphasises iteration and adaptation, allowing healthcare providers to refine preventative programmes based on real world outcomes. Through continuous improvement and proactive risk management, healthcare services can focus on long-term health objectives, supporting preventative efforts that benefit both individuals and the broader health and social care system.  

As part of the Academy’s series of People's AI Stewardship Summits, we spoke to 30 members of the public in Glasgow about the role of AI in reducing health inequalities. They identified prevention as a key opportunity, from providing targeted public health messaging that resonates with individuals to enabling localised intervention based on intersectional demographic data at a community level allowing decisionmakers to get the right resources to the right places.  

Prevention must be seen as broader than early identification and intervention in disease pathways. The environment can also contribute to the prevalence of conditions such as cancer, heart disease and respiratory infections. The COVID-19 pandemic highlighted the vulnerabilities in the UK's built environment and public transport systems. Embedding infection resilience into the design and management of these spaces, as well as more effectively in health and care settings, is crucial for preventing the spread of future pandemics and seasonal outbreaks. This involves setting infection resilience standards, updating building regulations, and aligning retrofitting projects with health goals. Proactive measures such as improving air quality, raising public awareness, and creating safer indoor environments are key to safeguarding public health. Prevention in this context extends beyond healthcare settings and should be applied to all public and private spaces. These interventions are beyond the scope of the NHS, but embedding health outcomes in infrastructure initiatives will reduce the downstream impacts. 

Managing the quality of indoor environments such as hospitals and homes, particularly air quality, can tackle the causes of ill health and spread of disease. As highlighted in the National Engineering Policy Centre’s Ventilation Matters report, the buildings and spaces we use daily have a significant impact on health. Factors such as ventilation, space, noise, temperature, and light all influence air freshness, comfort and cleanliness. Poorly ventilated public buildings or homes allow pollutants and infectious agents to accumulate, including issues such as mould and damp increasing the risk of respiratory illnesses and other health issues.  Effective ventilation is essential: without it, buildings can become "stagnant" spaces where pathogens spread more easily. Therefore, prioritising well-ventilated, healthy indoor spaces not only helps reduce illness transmission but also supports overall public health by providing safe, breathable air and should be considered in similar terms to the need to provide clean drinking water. 

These recommendations are based on a systems engineering approach, which integrates the various components of the healthcare system to deliver more effective, coordinated care. The Academy would be happy to discuss any of these policy ideas in more detail.

Quick to do, that is in the next year or so  

Appoint a Systems Leader to Integrated Care Boards 

Currently, no single person or team is responsible for ensuring the join-up between different services within local care systems – a role akin to that of a Chief Engineer in the engineering industry. The creation of Integrated Care Systems in England has set expectations for local systems leadership and collaborative action against shared challenges, and Integrated Care Boards have a pivotal role to play in enabling systems-lead improvement. However, resources and capability are currently limited. Integrated Care Boards should appoint a Systems Leader who has the responsibility and authority to oversee and manage the interfaces between different health and care services. This role would bring dedicated capability and capacity for system-wide innovation, empowering staff to design and implement effective, efficient, resilient solutions so that patients get the right care at the right time. This intervention would empower local care systems with the tools they need to identify the right challenges to solve and to continuously improve. 

In the middle, that is in the next 2 to 5 years  

Establish a Centre for Systems Innovation in Health and Social Care 

This Centre is predicated on the need for a health and social care system that delivers for patients and staff – with a focus on prevention, short waiting lists, brief hospital stays, and care provided in the community, supported by the safe use of new technologies such as AI. The establishment of a Centre aligns with recommendations outlined in the 2021 Council for Science and Technology (CST) report, Harnessing Technology for the Long-Term Sustainability of the UK’s Healthcare System.

There are a range of initiatives that seek to improve the quality of care in a systemic way, but no function that has the capacity, responsibility and toolkit to look across the whole of the UK health and social care system and to deliver radical and effective improvement. Such a Centre would not be a regulator or a mechanism for oversight, but rather a mechanism for active support, stimulation of action and building capability. Its operations would be underpinned by principles of being independent, collaborative, outcome oriented and ambitious.  

A key role of the Centre would be to drive the adoption of better ways to deliver radical and effective improvement through partnership. The Centre would collaborate with Integrated Care Systems, or equivalent structures, and their frontline staff, and would draw on expertise from engineering, computer science, and behavioural and social science, to provide systems thinking and delivery capabilities to help them to identify the right problems to solve for the challenges they face, and to co-design, implement, iterate and evaluate transformative solutions at scale.  

Establishing the Centre as a central hub would be important to facilitate knowledge exchange between care systems and to identify the cross-cutting lessons, allowing the Centre to catalyse meaningful innovation in local and national transformation efforts. The Centre would also develop and deliver robust monitoring and evaluation of improvement project outcomes. 

The Centre could build a shared understanding of the health and social care system, its objectives, the interactions and antagonisms between its parts, and would support ambitious and cost-effective systems improvements at local and national levels.  

The Centre could support government in delivering its policy outcomes but requires external, technical expertise, independence and political impartiality to focus on long-term systems improvements. 

Data infrastructure 

Current fragmentation of patient data within and between NHS and social care systems prevents effective early detection of health issues and limits coordinated care. Establishing secure, connected and interoperable data infrastructures is critical to ensure that all relevant care providers—be it in hospitals, GP practices, or community care—have timely access to accurate, up-to-date patient information. This would enhance preventative care, reduce duplication of effort, and streamline care processes, leading to better outcomes and a more efficient use of resources. However, this requires setting the right foundations with secure IT systems, reliable IT equipment, interoperable tools and essential digital skills, and setting the enabling conditions for more advanced data driven innovation. 

The engineering community can support the development of such a data infrastructure in a secure and reliable way, to avoid the failures of previous complex health IT projects. 

Long term change, that will take more than 5 years 

Systems upskilling 

For long-term change, the Academy recommends training in systems thinking tools for all health and social care service leaders. Embedding systems thinking into the educational and professional development of healthcare leaders will empower them to think holistically about care pathways and problem-solving. Such training would help staff understand the interdependencies within the healthcare system, anticipate bottlenecks or risks, and apply continuous improvement principles in their day-to-day tasks. Over time, this culture of systems thinking will become embedded, leading to a more resilient, efficient, and patient-centred healthcare system. 

A Centre for Systems Innovation in Health and Social Care could play a core role in providing training for systems leadership and improvement, and in facilitating the exchange of knowledge and best practice.