29.05.18
The work of the vanguards can help overcome the challenges of integrated care
Following the announcement of the second wave of integrated care systems (ICSs), NHS Providers, the NHS Confederation, NHS Clinical Commissioners (NHSCC) and the Local Government Association (LGA) reflect on how lessons learnt by members from across the four organisations – that have designed and worked together as part of the vanguards – will support the journey to integrated care. Here, Chris Hopson (chief executive of NHS Providers), Niall Dickson (chief executive of NHS Confederation), Julie Wood (chief executive of NHSCC) and Cllr Izzi Seccombe (chair of the LGA Community Wellbeing Board) discuss why it is vital that the legacy of the vanguards is shared.
The national New Care Models (NCM) programme was seen by some as a ‘game-changer’ when it was launched by NHS England in 2015 – setting the template for patient care in the 21st century. Its vision was to deliver lasting change in the way that people access and use local health and care services in line with the ambitions set out in the Five Year Forward View.
Niall Dickson, of the NHS Confederation, described this challenge as “enormous,” with the health and care system needing to recognise “that unless we manage demand by providing the right support at the right time, the system cannot be sustained, even with more staff and more funding.”
Chris Hopson, of NHS Providers, added that the programme itself needed to recognise “that large-scale transformation in healthcare requires funding, implementation support, time, and the permission to make mistakes and learn from them.”
The vanguard sites across England have made strides towards realising those ambitions and setting out a blueprint towards integrated care. Many have introduced innovative approaches to delivering care that can be shared and spread at scale, while also building strong partnerships across traditional boundaries, overcoming complex governance challenges, and involving staff, patients and the public in service change.
Three years on, it is time to consider the legacy of the vanguards and to ensure that the lessons learned by those involved will make a positive contribution to health and care in the future.
What have the vanguards achieved?
At the end of the first year of the NCM programme, there were 50 vanguard areas working to improve care for more than five million people, around 9% of the national population.
Across these sites, there were five vanguard types set up:
- Multispecialty community providers (MCP), combining primary care and community-based health and care services;
- Integrated primary and acute care systems (PACS), joining up primary care, community and mental health services and also incorporating hospital services;
- Enhanced health in care homes, bringing together NHS services in partnership with care home providers and local authority services;
- Acute care collaborations, testing new ways for acute providers to work together to improve care quality, financial efficiency and workforce sustainability;
- Urgent and emergency care, coordinating urgent and emergency care services across whole systems and ensuring people can access the most appropriate service, first time.
Julie Wood, of NHSCC, is positive about the changes that the programme has delivered: “Over the three years of the vanguards and NCM programme, we have witnessed many of our members leading and delivering truly innovative work that has radically changed the way that people receive care – resulting in a more coordinated approach and improving outcomes for patients and the wider population.”
Dickson added that the programme has “demonstrated an array of initiatives that have created new relationships, removed barriers, harnessed technology, empowered staff, patients and communities and connected up services.”
Partnership working has been at the heart of these successes. Cllr Izzi Seccombe, of the LGA, noted that for new models of care to be successful they must be based on “partnerships of equals between councils, the NHS and the community, based on a strong vision co-produced with all stakeholders including the public.”
Vanguards, such as Tower Hamlets Together and My Life A Full Life on the Isle of Wight, have demonstrated the power of different parts of the public and voluntary sector coming together to support population health and wellbeing in their broadest sense. Through their focus on multi-disciplinary team (MDT) working, sharing information across services and using technology to support self-care, many vanguards are starting to truly design care around the needs of people who use services.
The All Together Better vanguard in Dudley has reported that implementing GP practice-based MDTs involving social care, mental health and voluntary sector workers has led to a reduction in patients’ length of stay. MDT working has also had a positive impact on staff levels of job satisfaction.
Whilst considering the next steps to integrated care, NHS England is also undertaking work to evaluate the impact of these reconfigured services and how they have improved the experiences of people who use them. This evaluation will also seek to set out the measurable impact on the local health and care economies.
The latest data shows that growth in emergency admissions has slowed in vanguards areas compared to other parts of the country. For the 12 months to January 2018, compared to the base year 2014-15, emergency admissions growth was 1.4% in the MCP vanguards and 1.7% in the PACS vanguards, against 5.7% growth across the rest of England. For the enhanced care homes vanguards, emergency admissions for residents dropped by 1.4% while admissions for the rest of the England went up by 6.7%.
The programme has demonstrated the value of bringing people together to network and share learning. The spread of the ‘Red Bag’ initiative developed by the Sutton Homes of Care vanguard to other parts of the country including Wakefield and Hertfordshire is a perfect example of why the national commitment to supporting spread and scale has been so important and must continue.
The ‘Red Bag’ keeps important information about a care home resident’s health in one place so that it is easily accessible to ambulance and hospital staff if the resident needs to go to hospital in an emergency. It also has room for personal belongings (such as clothes for day of discharge, glasses, hearing aids, dentures) and it stays with the patient while they are in hospital. When the resident is ready to go home, a copy of their discharge summary is placed in the red bag so that care home staff have access to this information when their resident arrives back home.
Where do we go next?
The wider system is now taking broad steps towards more joined up care through ICSs and sustainability and transformation partnerships (STPs).
Hopson warned that we as we begin this journey, we must not interpret the successes of the vanguards “to mean that health and social care services can be expected to maintain, or accelerate, the speed at which they are delivering new models of care.”
He acknowledged that “an incredible amount is being achieved by committed health and care staff, from right across our respective memberships, to develop new models, while also keep existing services running.” However, “leadership and management capacity in the health and care systems is at full stretch.”
Dickson agreed, adding: “Our members tell us trying to bring about transformational change, with little or no extra money, while trying to sustain the existing services is exceptionally difficult.”
He suggested that the real value of the NCM programme can be seen in the lessons shared from those involved in the vanguards, now supporting this journey. “If we can continue to share the lessons learned from the vanguard sites across the health and care system, there will be real and lasting value,” said the NHS Confederation boss.
Wood also argued that these “lessons must be embedded and not lost as work across the system scales up, ensuring the patient benefits from the transformation agenda are realised.”
Time to build on the experiences of the vanguards
Looking to the immediate future, it is evident that STPs and ICSs are the vehicles to put the lessons from the vanguards into practice. The next wave of ICSs represent an opportunity to build on the experiences of the vanguards and capitalise on the enthusiasm and leadership of vanguard partners and their local communities.
Dickson argued that it is critical that we “maintain momentum and capture the energy and enthusiasm from the clinicians and staff from across the NHS and local authorities that have shaped and led these innovations.” One element of this will be to “establish an innovative culture which fosters and supports these new models of care.”
Wood suggested that “now is the time to build on new partnerships, make the most of opportunities to bridge the gaps between different areas of the country and across clinical disciplines, and share best practice to scale up and deliver long-lasting change.”
At the heart of this, Seccombe stated that we must continue to place importance on “shifting the centre of gravity towards joined-up primary, community and social care – as these frontrunners have shown – to support people to stay well, independent, safe and happy.”
There is much to be learnt from the work of the vanguards, from how they have engaged local communities to help people stay well at home, and supported staff to deliver service change on the ground. While it is evident that this has produced positive changes, as Hopson explained, we need to be realistic about the challenges of scaling up and spreading these models. “Applying this learning to transformation on a much larger scale will present us with new set of challenges,” he concluded.
NHS Providers, NHS Confederation, NHSCC and the LGA have produced a briefing series to help share learning from the vanguards.