Engineering a healthier NHS

The scale and complexity of the NHS's challenges is staggering:

• As of February 2025, more than 6.2 million people were on NHS waiting lists for treatment, with many facing delays of over a year.
• A&E waiting times have increased substantially over the past decade.
• There are currently more than 25,000 vacancies of nurses, midwives and health visitors, contributing to chronic staff shortages and increased burnout.
•  Delayed discharges remain a critical issue due to poor integration between health and social care services.
• The UK’s ageing population presents an increasing demand for care, with many patients managing multiple long-term conditions.
• Public health challenges – including obesity, mental health conditions, and preventable diseases – continue to rise.

These issues do not exist in isolation. Decisions made in one area of the system often have unintended consequences elsewhere. Addressing them requires a shift from reactive, short-term solutions to integrated, system-wide change.

This is where systems approaches comes in. 

At its core, a systems approach is about understanding and managing complexity. With its origins in diverse disciplines, such as systems engineering, social science, design thinking, risk management, operations research, service design and software engineering, it provides a structured way to understand, analyse, and improve interconnected systems – making it particularly relevant to health and care.

Unlike traditional approaches that tackle individual problems in isolation, a systems approach considers the bigger picture – how different components interact, where inefficiencies arise, and how improvements in one area may impact the rest of the system.

This holistic approach is essential in a setting as intricate as the NHS, where patient care, workforce management, technology, and policy are deeply interwoven.

To apply this thinking in health and care, Professor Clarkson, director of the Engineering Design Centre at the University of Cambridge and co-director of Cambridge Public Health, along with colleagues at the Royal Academy of Engineering, developed the Engineering Better Care framework – a structured methodology designed to help teams analyse problems, identify solutions, and implement meaningful, system-wide improvements. It is built on four key elements, or perspectives.

Transforming frailty care: a systems approach in Cumbria

Frailty is a growing challenge for the NHS, with older patients frequently experiencing fragmented care and unnecessary hospital admissions. To address this, the Lancashire and South Cumbria Integrated Care System partnered with the Engineering Design Centre to apply systems thinking to frailty care.

Working with five NHS trusts, the research team provided training to NHS improvement leads, supporting them through regular ‘think tank’ and ‘do tank’ meetings. These sessions brought together frontline providers to explore both strategic and practical solutions.

One major outcome was the development of a standardised clinical frailty scale, helping health care professionals use a common language to assess and manage frailty more effectively.

Additionally, NHS Midlands and Lancashire collaborated with local teams to co-develop an interactive dashboard, integrating multiple data sources to track improvements, assess care processes, and support clinical decision-making.

Now embedded within the Lancashire and South Cumbria health system, the dashboard is guiding system-wide improvement initiatives, including the implementation of a unified care plan template, helping reduce unnecessary hospital admissions and improve patient care.

Understanding systems thinking is only the first step. Embedding it in health and care requires raising awareness, training professionals, and developing systems leaders.

In engineering-led industries, major projects employ chief engineers whose primary role is to ensure that every part of a system integrates effectively. The NHS lacks an equivalent role – someone whose primary responsibility is to see the system as a whole and ensure different elements align effectively. However, systems thinking should not be confined to leadership roles alone. Embedding a systems perspective across all levels of health care can drive meaningful change. When all health care professionals – from frontline workers to administrators – understand how their role fits into the broader system, they can better anticipate consequences, collaborate more effectively, and contribute to long-term improvements.

This approach fosters systems leaders at every level. A ward nurse improving patient flow, a hospital manager redesigning care pathways, or a chief executive implementing integrated care – all can play a role in making the NHS more resilient. Regardless of title, these individuals need the authority and permission to challenge system inefficiencies across traditional boundaries to create lasting improvements.

As the NHS faces mounting pressures, systems approaches can offer a clear path forward. By shifting from a reactive problem-solving to a proactive outcome-led systems-design approach, we can support the creation of a health care system that is not only efficient and effective but also equitable and sustainable.

Adopting a systems-thinking mindset at all levels of the NHS is essential for creating long-term improvements. By embedding systems thinking into everyday practice, we can build a health and care system that not only meets current challenges but is also prepared for the complexities of the future.

The journey will not be easy, but the potential benefits are enormous: better care for patients, improved working conditions for staff, and a healthier future for the nation. 

At the Engineering Design Centre at the University of Cambridge, researchers are applying systems engineering approaches to improve health and care across a range of areas – from enhancing mental health discharge pathways to developing digital tools for Alzheimer’s assessment and improving surgical care in low-income settings. In the coming months, we will explore these initiatives in greater depth, demonstrating how systems thinking can help tackle some of health care’s most complex challenges.