I wonder if Prime Minister Johnson knows why, just this once, something he is trying to do is actually working..

Last week I received my first dose of the Pfizer/BionTech vaccine. Like many across the country, my large GP practice has joined up with others to create a vaccination hub. They had created an assembly line where we were met by volunteers, organised by admin staff, and then sent to one of a number of spokes of nurses and GPs for vaccinatation. As far as I could judge they were vaccinating about one old person every 45 seconds. It was very smooth. Every part of the process was organised to move us through it quickly and safely. When we were sitting for the regulation 15 minutes after the jab, each seat was fitted with an electronic timer which beeped after 15 minutes to remind us to leave to make room for someone else.

I came home to find that I was one of 3 million who had already had the jab.

Over the weekend the papers were a bit stunned by how well it was all going. After 10 months of chaotic Government implementation – even many of the Government’s supporters were a bit puzzled as to why and how the vaccination programme was working. It looked – surprise, surprise – that the Government might actually hit an important target.

How had such an unlikely event occurred?

Well if he had really paid attention the Prime Minister could have learned something about how Government implementations can sometimes work – and why they so often don’t.

During my career I’ve not spent a lot of time working with other health care systems to be able to compare and contrast them with the NHS. But on every occasion that I have everyone agrees that the NHS beng a universal primary care system which works with local populations registered to a local part of that system, is a very important aspect of our health service.

Quite rightly those systems that do not have such universal primary care are jealous of it and reflect on how this part of our system would, if imported to theirs, improve not just their national health care – but also the health of their national population.

Many people working in other national health systems are a bit stunned by the twin facts that we have a nationalised hospital system where the NHS hospitals are owned (foundation trusts notwithstanding) by the state. And yet we have a national primary care system based upon a set of small businesses which are separate organisations both from each other and the state that pays for their work.

Why do we have such two very different systems? This puzzle has always provided me with an opportunity to reprise my 1946-1948 post war political lecture. Here Nye Bevan takes on and beats the doctors who wanted to stop the NHS at birth. He was allowed to nationalise the hospitals so long as he allowed GPs to run their own small businesses. It was clever politics and even if it left us with two very different organisations of two parts, that politics delivered the NHS.

And here we are with two very different parts of the NHS. I have spent (this blog passim) lamenting the difficulty that the NHS has in getting these two systems – nationalised hospitals and small business GPs – to work together. Integration is hard and essential. What can’t we have one system organised in one way?

And in a very strange way the success of the vaccination programme is my answer. It’s been important to have two systems.

Look at the current news bulletins. At the moment the first two items of every bulletin are about the NHS.

The first reports that the NHS is under almost impossible pressure from working with so many people very ill with Covid. There is a real worry – every day – that the NHS may be overwhelmed by the number of very sick people infected with the virus.  Every night, every news bulletin shows us very worried consultants and CEOs warning that the NHS may not be able to cope in the next few days. This part of the news is very scary and we are quite rightly filled with gratitude at how kindly and consistently people are working to save lives and not to be defeated.

Then the second item tells us the number of people being vaccinated. This same NHS that is in danger of being overwhelmed has, at the same time and from a standing start, organised the vaccination of over 2 million people a week.

Taken together, these first two news items should raise the question that no-one seems to ask. How can the NHS be nearly overwhelmed AND at one and the same time, ramp up to carry out more than 2 million vaccinations a week?

The answer is that there are two distinct parts of the same NHS. A nationalised hospital service and a localised primary care service. And whilst some of the initial vaccinations were carried out by hospitals, the bulk of the heavy lifting of the vaccination programme that will take place between now and July will be carried out by our localised primary care system.

Given his very poor track record of delivering the implementation of policy, the Prime Minister appears to be correctly anxious that he may not hit is mid-February vaccination target. After all his implementation hasn’t before. So why, on this occasion, should this target be hit?

If he was paying attention what lessons might he draw for the future?

First, when faced with a crisis that calls for immediate implementation, don’t ignore the systems you already have. Rather than trying to create a new system from scratch, look closely at what there is at the moment and build upon that. Of course there are things that are wrong with the existing systems, but work out how to use them better rather than thinking that in the teeth of an immediate crisis you should set up something completely new.

Second, don’t believe that your mates (and their wives) are best placed to move the existing system to do something fast and big. Just because they are your mates (and their wives) doesn’t mean that they are better than the people who have been doing it already. To get people delivering a service to work very hard for several months, you will need chains of command which they trust.

Third, recognise that if you want to reach tens of millions of people across the entire country, you will need a delivery mechanism that is already a part of the locality where people live. People live their lives here, here and here. They don’t live their lives in the centralised world of Number 10. You will need to implement your policy in thousands of localities. Implementation with the population is essentially a decentralised reality. Think how your small centre can work with that decentralised reality.

For several months the Prime Minister made these mistakes with test and trace.

Those of us who have had our jabs and those of you who will get them at record speed in the next few months, have to be thankful that the NHS did not allow him to make those same mistakes with the vaccination programme.