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New Care Models: lighting a fire

Michael Macdonnell, national director of health system transformation at NHS England, reflects on the achievements of vanguards so far, and outlines the three key lessons they offer to ensure new care models become a bottom-up blueprint for future integration.

When the New Care Models programme was launched in 2015, NHS England chief executive Simon Stevens said: “We’re firing the starting gun… on radical care redesign.”

Instead of the usual top-down administrative tinkering, the NHS was given licence to shape the way care should be delivered.

Fifty new partnerships in health and care, called vanguards, were created. Together they covered nearly 10% of the population.

The initial three-year life of the programme finished in March, but the platform it created and the learning generated is now being taken forward by integrated care systems. These herald a new collective responsibility across both commissioners and providers of care, with the aim of improving the health and healthcare of the larger populations they serve.

The ambition of the vanguard programme was to spearhead a bottom-up approach to designing new ways of delivering care, putting clinicians in the driving seat.

These partnerships became the leaders in integrated care, with the national programme taking the common features of the most successful vanguards to create a replicable blueprint for other areas of the country to use as a framework in their plans.

Multispecialty community providers

About 14 vanguards became multispecialty community providers (MCPs), the essence of which is a re-energised model of primary care that provides expanded access and services to the population. Working in multi-disciplinary teams, GPs proactively coordinate care for those who are at risk of acute deterioration and hospitalisation. They help patients better manage their own health and wellbeing, particularly those most at risk, with support from professionals closer to home.

In South Hampshire, patients with respiratory diseases are able to visit a carousel clinic where they could have all the necessary tests while seeing other professionals, including psychologists, physiotherapists and dieticians. Their analysis of the impact shows a 67% reduction in A&E attendances and a 49% reduction in primary care visits from that patient cohort.

Across all 14 vanguards, the growth in emergency admissions has been much lower than other parts of the NHS. In January this year, the growth rate for 2017-18 was running at 5.7% for the rest of England, compared to 1.4% for these MCPs.

Primary and acute care systems

There were also nine integrated primary and acute care system vanguards. This model of care integrates hospitals with GPs, mental health and social care services.

Mid-Nottinghamshire Better Together vanguard introduced integrated locality teams to provide targeted treatment to patients at high risk of hospital admission. This reduced demand to such an extent that Sherwood Forest Hospital was able to make yearly savings of £20m to reinvest into patient care.

By proactively caring for people at risk of hospitalisation or readmission, these vanguards have constrained emergency admissions growth to 1.7%.

Health in care homes

Six vanguards targeted enhanced health in care homes, joining up services to prevent deterioration and reduce unnecessary hospital admissions.

Wakefield, for example, reduced ambulance call-outs by 9% and bed days by 26%. Similarly, in Sutton bed days for care home residents in hospitals fell by 18%.

Emergency admissions for all the care home vanguards has actually fallen by 1.4% compared to an increase of 6.7% for the rest of England’s care home population. Total bed days have decreased by 4.5% as opposed to an increase in non-vanguard areas of 1.4%.

Acute care collaborations

The final group of vanguards involved 13 acute care collaborations. They have created new hospital groups and networks to standardise clinical pathways and improve care in a range of specialties, including women and children’s services, neurology, cancer, mental health and eye care.

The Northumbria Foundation Group spread a quality improvement programme for patients with hip fractures to six other organisations. This gives patients quicker access to surgery and improves pain management. These changes, amongst others, led to 30-day mortality falling from 14.3% to 8%.

Collaboration has also demonstrated operational efficiencies and significant cost savings. The Working Together Partnership in South Yorkshire used a joint procurement approach across seven hospital trusts to generate £2m of savings for items such as examination and surgical gloves, needles, sutures and dressing.

Three lessons for change

The impact of the vanguard programme will be felt for many years. Evaluation is ongoing, but the legacy will drive the implementation of integrated care systems. Five out of the 10 first wave integrated care systems are operating over one or more existing vanguard footprints – and the learning and evidence from vanguards has been critical for accelerating change in these systems.

The King’s Fund chief executive, Chris Ham, recently said: “As the new care models approach their third anniversary in 2018, there is much to celebrate. As national funding and support comes to an end, I am confident that their work will continue and in many cases be extended.”

Nationally, three critical characteristics required for successful change have emerged.

First, systems need to lay the foundations for collaboration between organisations that have previously competed. Without trusting relationships, integrated care can’t happen.

Second is the importance of analysing the needs of the whole population and redesigning care around those most at risk of falling ill or ending up in hospital. This requires a sophisticated mix of data and clinical behaviour change.

Third, new care models blur traditional professional boundaries. Not only do GPs, hospital specialists and local government officers need to work together differently, we also need to introduce new roles like care navigators or coaches, primary care-based pharmacists and therapists. Successful integrated care offers the opportunity for doctors, nurses and allied health professionals to take on greater responsibility, develop their skills and work to ‘the top of their licence.’

Amidst the very real pressures in the NHS, it’s easy to forget how exciting these changes are. But they have certainly caught the attention of international observers. As the world-renowned health advisor Professor Don Berwick said: “You have created a thrilling vision of what the health and care system should look like. This is not ending; you have lit a fire.”

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W: www.england.nhs.uk