The challenges facing the health and social care system are considerable – with competing pressures from an ageing population, increasing numbers of patients with multiple morbidities, new technologies, and the need for increasing efficiencies. The complexity of the system, along with the multiple pressures it faces, mean that efforts to improve it often achieve only limited benefits and can have unforeseen consequences. Over the past two decades, there have been numerous calls to implement a more holistic systems approach to transform health and care to address the needs of a changing patient population. However, there has been no clear definition of what this might mean in practice.
Engineers routinely use a systems approach to address challenging problems in complex projects. This allows them to work through the implications of each change or decision they make for the project as a whole. They consider the layout of the system, defining all the elements and interconnections, to ensure that the whole system performs as required. One example is the successful delivery of the London 2012 Olympic and Paralympic Games. Physical infrastructure and practical organisation were brought together, with innovative physical engineering, modelling and simulation of people flows, early testing of venues, and extensive risk management. A systems approach, combined with tried and tested engineering methods and tools, delivered real success on a massive scale.
This report was co-produced with engineers, clinicians, and healthcare leaders, to explore how an engineering approach could be applied in health and social care to develop systems that meet the needs of patients, carers and NHS staff. It presents a new framework to support ongoing work in service design and improvement in health and care.
“Systems that work do not just happen — they have to be planned, designed and built” 
All health and care improvement initiatives involve people, processes, technologies, the physical environment and systems that, in turn, are part of other systems.For example, the care pathway of an elderly frail patient must meet the needs of the patient, their immediate carer and wider family. Care must also coordinate across community support, a GP practice and hospital teams, and manage the patient’s medication, their physical journey to and around healthcare facilities, home care technologies and associated health and care data. Such complexity means that health and care will benefit from using an approach that considers each relevant element of the system and, critically, the nature and performance of the interfaces between them.
Comparing current health and care improvement processes with engineering systems approaches, we found that:
There is the potential for health and care improvement to benefit from the rigour of the engineering approach to systems, particularly with respect to:
systems being centred on people – an effective systems approach is centred on people, their needs, their capabilities and ultimately their role in understanding, designing, delivering and maintaining success
iteration before implementation – the behaviour of complex systems is not easily understood and improvement is most often the result of successive iterations targeted at maximising the chance of success prior to implementation
design as an exploratory process – improvement results from a creative process that seeks not only to explore the real need, but also to evaluate a range of possible solutions in order to select the best option
risk management as a proactive process – the identification of possible opportunities for and threats to a system before they arise is more likely to lead to the delivery of robust and adaptable systems.
While islands of excellence exist in the use of a systems approach in healthcare, the common sense thinking presented here is still far from being common in practice.
A systems approach can be defined and applied in a health and care context as a series of questions that integrate people, systems, design and risk perspectives in an ordered and well executed manner. It is only when all four are robustly understood and considered that a systems approach will have the greatest success.
These findings from this collaborative project have been integrated into a framework that can support the work of transformation teams and individuals. These tools can help facilitate the methodical application of a systems approach to improvement, dealing with complexity and improving performance. This approach can be applied to systems across all scales in the healthcare system, from service level improvement, through to organisational, cross-organisational, or cross-sector level change.
In summary, we found that more widespread application of a rigorous systems approach to health and care improvement, has the potential to have a transformative effect on health and care, with benefits for patients, service users, and providers.
We encourage transformation teams to test out the framework, and invite more partners to join us in the next phase, trialling and implementing this approach and augmenting what we have proposed.
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 Creating systems that work: Principles of engineering systems for the 21st century, Royal Academy of Engineering, 2007.