Let’s introduce systems management and engineering supported by robust programme and project management and get the NHS to work together as an integrated whole, writes David Lee

Here’s a simple question – what’s the best way to improve the way the NHS works? The answer is, we don’t really know.

Writing in the British Medical Journal , Professor Mary Dixon-Woods, director of The Healthcare Improvement Studies Institute at Cambridge University highlights that quality improvement has been advocated for the last 30 years, “Yet the question, ‘Does quality improvement actually improve quality?’ remains surprisingly difficult to answer.”

She goes on to say, “The sobering reality is that some well-intentioned, initially plausible improvement efforts fail when subjected to more rigorous evaluation.” (BMJ 2019;367:l5514)

So, what should the NHS do? I suggest watching the 2019 Apollo 11 documentary.

This film showed US president John F. Kennedy in 1962 setting out the straightforward aim of sending a giant rocket safely to the moon and back by the end of the decade – which of course NASA achieved.

Lessons to be learnt

Why should we look at the lessons from Apollo 11? The answer lies at the top of government. Dominic Cummings, chief advisor to the prime minister, thinks it offers a blueprint to change how government works and has written a detailed blog post about it.

So what was special about Apollo 11? Here was a massive programme which employed 376,000 people (most of them working for contractors) and cost $25bn.

George Mueller, who took charge from 1963, had to get scientists, engineers and managers to work together across multiple organisations. Mueller himself was all three – he was an engineer, a scientist and a manager and combined a unique understanding of everyone’s skills in order to make Apollo 11 a success.

So, how did he do it?

First, total clarity of purpose – easier for Apollo 11, harder for the NHS. The NHS has too many objectives, priorities, visions, values, aims, ambitions and vaguely described plans and initiatives for staff to understand what exactly it is they are supposed to be delivering.

Second, systems management. This involves looking at the whole system, or as Mueller put it, “a structure for visualising all the factors involved as an integrated whole.”

This runs together with systems engineering which involves managing the physical changes and interactions across systems to make sure the change is delivered. The NHS doesn’t do this. Instead there are multiple individual NHS organisations with multiple interactions, with each interaction a potential (and in many cases an actual) point of failure.

Here’s a current example of where systems management would benefit the NHS. NHS England is currently shovelling money at primary care to hire social prescribing link workers. But there is no robust evidence that this model actually works.

And other parts of the system are withdrawing funding from the community groups which could help people referred by link workers. So we may end up with lots of link workers wondering where to refer people on to.

In fact social prescribing throws up two other elements of Apollo 11, configuration management and all up testing. Apollo 11 shortened timescales by live testing all elements of a space prototype at once and used configuration management to ensure that everyone was using the exact configuration of any change or development which worked. If NHS England had used this approach then it would have identified a robust social prescribing model which worked and then ensured that everyone used it.

Third, information and communication. Mueller set up new information flows to ensure everyone knew how to receive and communicate information. Mueller later said that,” so many programs fail because everybody doesn’t know what it is they are supposed to do.”

To ensure everyone knew what to do and did it, Mueller introduced a comprehensive and structured programme and project management approach. In the Apollo 11 programme contractors had daily schedules of work to be completed.

Mueller set up control centres with those big information screens. He set up contractor meetings so contractors could all talk to each other and solve problems together. But Mueller didn’t like talking for talking’s sake. He scrapped the top level meetings which he quickly realised were just talking shops and replaced them with fewer groupings which focussed only on problems and mistakes which needed to be addressed.

Fourth, Mueller operated in an environment where there were fewer rules. Mueller later said that modern procurement rules would make Apollo 11 difficult today. Maybe Brexit will help with this.

So how can the NHS learn from the Apollo 11 mission? Let’s start with clarity of purpose. Ditch the confusion and adopt a clear purpose in everything the NHS does. Let’s address the devolved structure of the NHS – why does the same stuff have to be reinvented all the time all over the country?

Too many interfaces mean too many places where communication fails. And communication and information is still in the dark ages. If I were running the NHS I’d want a big room with big screens on the walls showing live data from every part of the NHS.

Let’s focus NHS meetings on mistakes and problems, however for the NHS this brings the risk of a blame and bullying culture. Let’s introduce systems management and systems engineering supported by robust programme and project management and get the NHS to work together as an integrated whole.

So, where’s the best place to start with all of this? There’s a lot of money in the NHS for improvement training and leadership training. Is it being spent wisely? The NHS has a Leadership Academy but not a Project Leadership Academy.

The good news for the NHS is that the government does have a Major Project Leadership Academy at Oxford University – so why doesn’t the NHS sign up?

The starting point of this Academy is that, “the Project Leader is seen as being best conceived as the Chief Executive Officer (CEO) of a large, temporary organisation (as opposed to a project manager engaged on a large project); and focussed on securing transformational outcomes.” Someone like George Mueller, in fact.

It’s tempting to say that all this isn’t rocket science, but of course it is.