Enabling change

Fast-paced change calls for detailed NHS knowledge to be finely balanced alongside fresh thinking and tried and tested methodologies from other sectors

With the Five Year Forward View heralding the creation of new models of care at pace, how can vanguard sites at the cutting edge of innovation be confident that they are headed in the right direction, and what does that mean for those organisations tasked with supporting change?
It has been just 20 months since the launch of NHS England’s Five Year Forward View and the acceleration in pace of change is palpable. NHS England’s vision is ambitious for good reason. Our health and care system is faced with unprecedented pressures and maintaining the status quo is not an option. With several potential new models of care outlined in the strategy, there are now 50 vanguard sites tasked with the challenge of leading the charge to develop new ways of working.
As we look to introduce new models of care, the support structures that have traditionally existed to enable transformation – be they commissioning, contracting or governance – are themselves having to change, ensuring that delivery is driven by the actual needs of local people. As a commissioning support unit (CSU), we, Arden and Greater East Midlands (GEM) CSU, are evolving in response to client needs, providing consultancy services dedicated to enabling change across wider health and care systems.

The changing face of CSU support
We have come a long way since the creation of clinical commissioning groups (CCGs) and CSUs three years ago, and exciting opportunities have been emerging to improve patient care through integrated partnership working.
Far from the early days of 25 CSUs, which stuck reasonably closely to the geographical make-up of the former primary care trusts and strategic health authorities, there are now just six, each offering a range of support services across a much larger geographical footprint. With the growing trend towards devolution, combined with increasing emphasis on strategic partnerships and joined-up working, organisations are increasingly being judged not only on their skills and ability to operate efficiently, but their approach to partnership working and ability to develop and implement new models of care.
The pace of change is quickening here too. As commissioners and providers look to adopt new ways of working, the pressure is on to provide faster outputs, whether that is in delivering initial proposals for work or the implementation of support services. In our case, we have seen a growing need not only to provide services outside our core region, but also for a new style of consultancy service built on core concepts and methodology that can be tailored to fit bespoke local requirements.
Alongside enabling change, there is a demand for high-quality data to drive and measure decisions, whether that is identifying needs, managing costs, understanding market characteristics or evaluating the impact of new services.

Applying logic
A good example of the drive for more consultancy-style support is the recent work we have undertaken with a range of vanguard sites to support them in developing their logic models, working with project teams as they develop their business case (referred to as a value proposition) for their new model of care.
In a nutshell, a logic model is designed to test the theory of whether something will work – “if I do this, I expect this output and these outcomes”. With the potential for a variety of care models and approaches, logic models are designed to map resources to interventions, ensuring that each value proposition follows a sensible rationale, with clear steps of progression and tested assumptions so that the new model of care will result in the desired outputs and outcomes. The logic model development process should challenge the validity of the value proposition and define detailed measurements for impact.
Working with private sector and academic partners, we are combining our extensive knowledge of the NHS and local delivery dynamics with leading expertise to unpick the various elements involved in developing a new model of care. This includes gaining a close understanding of the role of each stakeholder in enabling change, what measures can be put in place to identify the impact each element is having and how the model will be adapted if some elements don’t deliver the outcomes expected.

Measuring impact
In moving from theory to implementation, evaluation naturally plays an essential role. With the scale and complexity of the NHS in mind, we have to accept that developing new models of care will not be easy. Against a backdrop of tough targets and small margins for error, it is essential that we work on understanding individual elements of change and their impact so we can continually use findings to tweak implementation. When working in complex systems with large scale change, we also need to be pragmatic and not over-complicate our evaluation so that we don’t create confusion about which element of success to attribute to which fragment of change. We need to balance giving people the space to innovate with the ability to watch carefully and switch rapidly if elements fail.
Building on our logic model work with private and academic partners, we have developed a detailed and robust evaluation methodology to directly support vanguard sites as they implement new models of care. The evaluation framework has been built to assist organisations throughout the cycle of change – from positively influencing the design of a programme, to improving ongoing efficiency and effectiveness, and reporting what has been achieved.
Working at individual phases or sequentially across pre-implementation, implementation and post-implementation, the main aim is to identify ‘what works, for whom and in what circumstances?’ Underpinning this are six fundamental questions:
1 Should it work? Is the theory behind the programme plausible with a sound evidence base?
2 Can it work? What resources are required to implement the programme in line with the theory?
3 Does it work? Is there evidence to demonstrate that the desired impact and outcomes are being achieved?
4 What does it cost? What are the financial implications of the programme?
5 Is it worth it? Is the programme sustainable in the medium to long term?
6 Is it replicable? Is the programme, or aspects of the programme, replicable in other local health economies?
Our ability to operate as change management specialists has been borne out of a combination of NHS experience and partnership working. In delivering significant change, the NHS has much to gain from working with the private and education sectors, to fast-track development of best practice. However, it is the detailed knowledge of the healthcare and commissioning sectors, which is crucial in turning theory into practice – a role that CSUs are well placed to deliver.

Responding to future needs
Innovation is at the heart of the Five Year Forward View and effective delivery relies on strong partnership working to identify and implement robust solutions to the growing pressures faced in healthcare.
In this complex and fast moving environment, it is the responsibility of those of us providing support services to be sufficiently flexible and responsive, adapting our own service model to support shifting client needs. Together, we have the opportunity to think and act differently, to explore new possibilities and to build future models of care that are both sustainable and truly patient focused. l

Wendy Lane, consultancy services director, NHS Arden & GEM CSU.