The urgent and emergency care vanguards are overhauling 111 systems and moving activity out of hospital, but the constraints of finance and workforce shortages are a concern, HSJ has been told.

  • Enhanced 111 systems and keeping patients out of hospital are top priorities for urgent and emergency care vanguards
  • Workforce shortage seen as the biggest obstacle to transforming care
  • Financial constraints and inability to “double run” are a concern

Samantha Jones, NHS England’s director of the new care models programme, said in an HSJ interview last month that the “fundamental principle” for the vanguard sites is to “get on and do it”.

HSJ spoke to four of the eight urgent and emergency care vanguards to find out what improvements to their emergency care system they have prioritised, and the barriers to service change.

Priorities for vanguards

The four vanguards are each overhauling their 111 system to become a service that can meet all urgent clinical needs rather than just a signposting service. Patients will be able to book a GP or urgent care centre appointment, or speak to a rapid access mental health service or paediatric service, for example.

The South Devon and Torbay System Resilience Group will open two new urgent care centres and encourage self-care to try and keep patients out of hospital. Nick Roberts, chief clinical officer of South Devon and Torbay Clinical Commissioning Group, said if people are “empowered” to manage their conditions then that avoids increased hospital visits and “just building a bigger [accident and emergency]”.

It is developing shared patient records, as is the Barking, Havering and Redbridge vanguard. The east London project, the Barking and Dagenham, Havering and Redbridge System Resilience Group, has also developed software that can read GP notes, which will be used in its GP hubs and urgent care centres over the next few months.

Workforce is the biggest challenge

All four vanguards see workforce shortages as a huge challenge.

Dr Roberts said south Devon has a workforce shortage in a number of areas. He said it was difficult to attract staff to the South West. Talks are underway with Exeter University and Health Education England over the possibility of setting up a workforce unit in the region, he added.

“We’ve got a pharmacist scheme but we haven’t managed to recruit enough pharmacists at the moment despite there being quite a lot nationally,” Dr Roberts said.

Ed Diggines, GP partner and co-chair of the Barking and Dagenham, Havering and Redbridge vanguard steering group, said workforce is the “number one priority and the number one weakness in the whole plan”.

He added: “We struggle to recruit and we struggle to retain people in the area. It’s been a challenged area for so many years now. The trust is in special measures and it’s got some of the costs of being affiliated to London but doesn’t have the sexiness of west London or central London.”

‘Workforce is the number one priority and the number one weakness in the whole plan’

Stewart Findlay, chief clinical officer at Durham Dales, Easington and Sedgefield CCG and one of the leads on the North East Urgent Care Network vanguard, said: “Ultimately we are going to need to train up more people… In the short term, we are trying to encourage more of a skill mix so bring pharmacists into primary care, trying to use paramedics in a different way.”

Patrick Brooke, accountable officer at Solihull CCG, said vanguard leaders in the area were looking at trying to “upskill” the workforce and create multidisciplinary teams.

He added: “Where we struggle is with care home type workers, social care workers, domiciliary care workers and the care home market, which is not particularly large.

“In common with all areas of the country, if you’re moving towards a more primary care led model then you need more GPs and nurses, and they are not that easy to find at the moment.”

Dr Diggines said one of the biggest barriers to joining up the urgent and emergency care system was the “massive institutional blocks between different organisations”.

He added: “You can have a single pay structure [and] governance, but you still eventually reach the boundary between two organisations and you stop because there’s a layer of procedural middle management that is never completely up to speed with what all the visionary guys at the top are up to.

“The quickest way to make progress is to create shared roles between two organisations that are co-funded and both organisations are equally comfortable with that person being able to penetrate into the infrastructure of those organisations.”

Finances are a barrier to change

The majority of the vanguards HSJ spoke to said financial constraints meant it would be difficult to “double run” services – to keep the existing service open while a new one is getting started. One vanguard leader said its “main barrier” was its finances.

They added: “We are very financially challenged and therefore when you’re setting up new services, the ideal is to double run so you can open your own urgent care centre and then have a conversation with localities about what we’re going to do with the small, less effective minor injuries unit. If you can’t double run, then you’ve got to close something before you can get the new service happening effectively.”

‘If you can’t double run, you’ve got to close something before you can get the new service happening’

Dr Diggines said the highest costs for the Barking vanguard would come from double running clinicians, particularly in primary care where there will be increased demand as activity moves out of hospital.

He said: “In this stage of remodelling it’s really difficult because somebody somewhere is going to have to do some double paid clinical work… but the workforce can only be downgraded over about a year or two, you have to give notice.

“That’s where the big cost is, that double pay. It’s where the dilemma is between the providers and the commissioners because there’s a huge amount of goodwill around partnership working but when it comes to it they’ve only got a certain amount of money in the pot. We hope the vanguard will bring a much closer alignment between all the providers and the commissioners.”

The vanguards will have access to a £200m transformation fund but have not yet been told how much they will each receive.