With sustainability and transformation plans only months away from implementation, Julie Wood, chief executive of NHS Clinical Commissioners, outlines the next steps for CCGs and the challenges they may face
For some, the term ‘vanguard’ conjures up the image of the post second-world-war English car, but for the Government it is a vehicle for change in the NHS. NHS England first announced the idea of vanguards in October 2014 in its Five-Year Forward View as part of its new models of care designed to provide primary care and secondary care in a single organism.
In January 2015, the NHS asked individual partnerships to request to become ‘vanguard’ sites for the new care models programme. In March, the initial 29 vanguard sites were chosen and then in September an extra 13 vanguards were announced. In total, the 50 vanguards are aimed to take a lead on the development of new care models which were assumed to pave the way forward for the NHS progressing.
The so-called vanguard sites have focused broadly on three areas.
NHS England now wants to encourage the vanguard sites to make formal arrangements that set out how the new collaborations of frontline staff will be funded and managed in the future.
Benefits to patients
But have patients benefited from these brave new ways of working? Have there been any demonstrable improvements?
Patches of data and anecdotal evidence are revealing a hopeful picture.
For instance, according to NHS England, the South Somerset Symphony Programme vanguard has achieved a 30% reduction in emergency hospital admissions, and reduced lengths of stay when patients are admitted.
It did this by identifying and focusing intensive, personalised support for the most complex 4% of patients using integrated care hubs and single care plans that can be accessed by both primary and secondary care.
Meanwhile, in Sunderland, Dr Fadi Khalil, chair of Sunderland clinical commissioning group’s (CCG) community integrated teams implementation group, says the local All Together Better vanguard has focused on integrating community teams to improve patient experience and outcomes. His vanguard has rejected a managerial approach and chosen to ensure that the form will follow the functional achievement of better care for patients.
As part of its drive to enable self-care and sustainability, the Sunderland MCP has introduced better recovery at home, post-discharge planning, step-up and step-down care, extra nursing, and re-ablement care packages that can help patients newly discharged from hospital to get back on their feet.
‘Patients now have individual care plans, they know who to speak to, and everyone is on the same page,’ says Khalil.
‘Weekly multidisciplinary team meetings that target the most complex and vulnerable patients are held in every GP practice, and this is part of the scale that is not replicated across the country.’ He adds: ‘We look at 3% of the population and actively manage an individual approach to their care. Every patient has different needs so you can’t have a meeting every month or three months.’
Rachel Daurat, a team manager in adult social care who works in the east locality of the Sunderland vanguard, says that before the creation of the integrated teams adult social care and health professionals did work together, but had difficulties with communication - not least because the teams were based in different buildings. Now, social work teams and district nurses are aligned with GP practices, and clusters that have patients in common sit together, enabling them to have inclusive conversations about improving care for that person.
‘It was daunting at first, but now we’ve gelled,’ she says. ‘Historically health and social care had different agendas, although the person was always at the centre. Now we can learn from each other, and we have regular team meetings with nurses to understand each other’s responsibilities.’
Prevention, recovery and self-care
Meanwhile, the PAC Happy Healthy at Home vanguard in North East Hampshire and Farnham has designed a new care model to improve prevention and self-care; strengthening primary and community care; and improving access to specialist care, partly through the use of a shared care record.
The vanguard says progress has been ‘rapid’ across its five localities, with a number of innovations already in place.
More than 250 students have enrolled on ‘recovery college’ courses – educational interventions that help people to live with a long-term condition. A ‘healthy living pharmacy’, which offers a wide range of services to support people in managing their own health, has been opened, with another soon to be accredited; and a social prescribing service that connects people with non-medical sources of support has been rolled out.
In September, NHS England published frameworks for common ways of working for PACs and for enhanced health in care homes vanguards. This was based on vanguard models around the country. A similar framework for MCP vanguards was published earlier this summer.
At the launch of the new framework publication, Samantha Jones, director of NHS England’s New Care Models Programme, said practical implementation of care redesign was now well under way across the 50 vanguard patches.
‘Learning about what has and hasn’t worked means we can now set out for the rest of the NHS what needs to happen in order to get concrete results.’
The community and voluntary angle
Progress is clearly being made, but Jeremy Taylor, chief executive of National Voices, a coalition of health and social care charities, regrets the fact that there has been no assessment of the level and nature of engagement with voluntary and community groups across the vanguard programme.
‘Anecdotally, there has been quite a lot of effort in the vanguard areas to develop holistic community-focused models of care and support involving the voluntary sector, but it is highly variable,’ he says.
‘We think there should be a formal evaluation and stock-take of what vanguards are doing differently. How do they engage with patients, communities and the voluntary sector? What is the nature of those different approaches? Which of them in these early days seem to be delivering promising results? And what can we learn from that evidence when rolling things out more broadly?’
Taylor welcomes the increase among vanguards of so-called social prescribing, where patients pass from medical care to social and community support provided through the voluntary sector, with the likes of walking and befriending groups.
‘There seems to be a bit of a movement with people fairly widely trying to adopt social prescribing methodologies,’ he says.
‘But we don’t know how embedded this is, how good it is, and whether any efforts are being made to build the capacity of the voluntary sector to provide this kind of support or whether it is piggy-backing on what is already available.’
However, the King’s Fund, which is supporting development of the new care models, is so far cautiously optimistic about progress.
The think-tank’s project director Ben Collins says that, bearing in mind vanguards began life as just half a dozen sentences in NHS England’s Five-Year Forward View, significant practical progress has been made.
‘The common theme emerging is that everyone is aiming, at least in the long term, to hand over a large pooled budget for a broad range of health services, and some social care services as well,’ he says.
He says it looks increasingly likely that commissioners will pool their money and hand it over as a single budget with a single contract to either one lead provider or an alliance or partnership of providers. The commissioners will then hold the providers to account for a ‘high-level’ improvement to the health of their population using that pot of money, rather than micromanaging individual services and monitoring against performance targets.
He says the vanguards are driving towards creating a system where providers have the power and motivation to make substantial changes to services.
‘A lot of progress has been made in terms of building partnerships and trust across a large number of local organisations, and in developing care models such as multidisciplinary community teams,’ he says.
‘So there has been significant progress in rolling out well-proven care models, but we do not yet have a commissioner who has formally handed over capitated budgets to a single provider or partnership.’