With NHS England’s vanguard sites established now for more than a year, HSJ was joined by some leading experts to explore their progress towards creating new models of care. By Alison Moore
In association with
It is now more than a year since the first vanguard sites for the new models of care outlined in the Five Year Forward View were announced by NHS England. Since then, the vanguards have been given transformational funding to put their ideas into practice.
But what progress have they made? What have been the barriers to making more? And, are other new models of care also making an impact? An HSJ roundtable explored these issues and heard from those involved in creating the new models.
HSJ editor Alastair McLellan, chairing the debate, highlighted the changing environment in which the vanguards have had to function, and how new priorities and ways of delivery had emerged over the year.
He said: “Sustainability and transformation plans have come to the fore. It is very clear from my conversation with Simon Stevens how he sees the STPs as his model of change.”
Andrew Willetts, healthcare solutions director at Celesio UK, had attended a similar HSJ roundtable a year ago, just as vanguards were announced. At that time, the discussions had been around vision.
Mr Willetts said: “Since then, we have worked and had conversations with many vanguards. What we have seen is a mixed picture.
“There has been great enthusiasm from some vanguard leaders and ideas. But we have seen mixed outcomes in terms of success.”
Next year’s model
Some of this related to the availability of funding, he added. But he raised the possibility that some of the vanguards were simply more successful than others and asked: “What does the next year look like? What models will we see start to take a lead?”
Jamal Butt, head of LloydsPharmacy Healthcare Solutions, which is owned by Celesio UK, said there was a question over how successful schemes could be adopted more widely to ease some of the pressures in the system.
One area where this would help the NHS was by increasing the use of pharmacists.
There has been great enthusiasm from some vanguard leaders and ideas. But we have seen mixed outcomes in terms of success
Mr Butt said: “Their help dealing with minor ailments in both secondary and primary settings would significantly ease pressure in accident and emergency departments and on GP appointments.
“To help co-ordinated care for patients it is important we have seamless communication between GPs and pharmacies – ideally with read-write summary care record capability. To speed up the pace of change, we need a different leadership mindset, shifting from sharing best practice to one of adoption.”
Northumbria Healthcare Foundation Trust is a primary and acute care system vanguard but one of the major changes in its first year has been the opening of an emergency care only hospital, which had obviously been planned before it received vanguard status.
Chief executive David Evans said that this had already had an impact with the “see to admit” ratios changing from 2.5 to 3.8 and a reduced length of stay.
Mr Evans said: “That has put a large chunk of money back into the system.”
The vanguard is also unusual in that the trust has run adult social care in the area since September 2013. This could have advantages for the acute side – for example, when someone is admitted to hospital for a short stay, their care package at home can be kept in place.
This means there is no delay in restarting their care package once they have been discharged – waiting for such packages to be put in place is a common reason why people remain in hospital unnecessarily.
Mr Evans said the STP process had meant that CCGs in the area were keen to work with the trust to deliver cost improvements throughout the system. He said: “The pace [of change] has been pretty good so far. If it had been any quicker, we would have been uncomfortable. Relationships were crucial in being able to start this.”
Another important factor had been IT: the trust and primary care partners now had better capacity and demand modelling, and those working in the community had mobile devices, which enabled them to securely access GP records. This had transformed the working life of many of them, he said.
He added that medications reviews – working with the Health Foundation’s Shine programme – had thrown up some interesting cases.
“We found one 90 year old lady who had been on 5mg of folic acid since her last pregnancy when she was 29,” he said.
The aim in Northumbria is to become an accountable care organisation within five years. “But we have local authority and other partners who are not as comfortable with that and they will drive the pace.’
One vanguard area that is already seeing significant changes – including in general practice – is Somerset.
Jeremy Martin, director of the Symphony Project that brings together hospitals, community services and GPs in the area, said: “Like Northumbria, we have been working on this for a long time. That has given us a head start.”
To speed up the pace of change, we need a different leadership mindset, shifting from sharing best practice to one of adoption
He outlined three years of moving towards a different way of working, with the impetus coming from a group of “like-minded people” who started to look at how changes could be made. This had included improving data, working on change models, and engagement with primary care.
Stratifying the population and identifying the 4 per cent of people who accounted for 50 per cent of NHS costs had been important, as had been investment in prevention and primary care. Concentrating on the most complex frail patients had begun to reduce hospital admissions by this group.
The challenge now was to scale this up and start making changes across the whole system.
“It has been a slow burn getting people on board,” he said. “However, the area that has exceeded our expectations is enhanced primary care – working to develop a new way of working in practices.”
Part of this has been introducing 40 health coaches to 13 practices. These dealt with patients who had been discussed at daily ‘huddles’ within practices and identified as needing extra input.
The health coaches’ work was varied but included visiting patients who had missed appointments and helping patients connect with other forms of help, such as the voluntary sector. Symphony also offered GPs closer co-operation with the foundation trust, something which has attracted several practices.
Mr Martin said: “A year ago that was not even being talked about. The bit that we are struggling with is how to do the longer term ACO. How do you create the pot to invest early on when you are not going to see the benefits for three to five years?”
In Hampshire, the multispecialty community provider vanguard is working on GP sustainability in an area where they were hard to recruit and there had been talk of some practices handing back their contracts.
However, Paul Streat, development director of Better Local Care, said there was recognition of the need to change among GPs and there were inspirational people who wanted to work with the vanguard.
“Our first year was about the engagement. This year is about what we are going to do with that engagement. I have been stunned by how much we can do without the incentive of contract changes. Our worry is that to do it properly is a two to three year process,” he said.
The advantage of having a foundation trust engaged with the vanguard was that its scale allowed risks to be taken. “We are doing act first, business case later,” he added.
Another important factor had been IT: the trust and primary care partners now had better capacity and demand modelling, and those working in the community had mobile devices, which enabled them to securely access GP records
Some early wins have started to emerge in vanguards looking at care homes. Beverley Flowers, chief executive of East and North Hertfordshire CCG, said work in her area had predated vanguard status and had identified a particular issue with A&E attendances followed by short admissions from care homes.
There were also staffing issues in many care homes with staff employees who only stay for a relatively short time and “churn” between similar jobs in different sectors.
“We have invested quite a lot in a training and development programme for care home staff. It’s making a difference in how staff feel valued,’ she said.
A team of pharmacists is also working with care homes, with the savings from their work quickly covering the cost of their salaries, she said. And there is also early evidence of a decrease in admission among the over 85s.
She added future plans could include working with care home agencies and their staff to address turnover.
Vanguards, while important, are not the only game in town as far as new ways of delivering and organising care are concerned. National Association of Primary Care president James Kingsland has been developing a different model of providing primary care and some community services – the Primary Care Home scheme that has 15 test sites moving towards holding a single capitated budget.
While not a vanguard, PCH has similarities with vanguard models. Dr Kingsland said PCH brought together the different parts of primary care to serve a community of between 30,000 and 50,000 people.
He said: “Size really matters. PCH is based on a registered list but it is aggregating it to a size where the workforce can still work as a team. You can’t do that with more than 50,000 people.”
PCH had been generating a lot of excitement, he added, and one of the attractions was that it was using existing assets in a different way. It was also driving behavioural changes in practice, and was enabling more episodes of care to be completed within primary care, supported by diagnostics and community services.
He said: “It is not returning to fundholding or total commissioning, or practice-based commissioning, primary care trusts or groups.”
The aim was that PCH sites would move towards holding their own budgets. He said: “A GP with a budget is worth 10 on a committee.”
But he also highlighted some of the challenges around change, saying he had been in practice for 27 years and had been ready to make changes throughout.
Size really matters. PCH is based on a registered list but it is aggregating it to a size where the workforce can still work as a team. You can’t do that with more than 50,000 people
Dr Kingsland said: “One of the things that has always impressed me about reform is that we do a lot of restructuring and not a lot of reforming.”
Paul Driscoll, chair of the Suffolk GP Federation, joked they were a failed vanguard – “we did not get accepted”. However, the federation was now providing community based diabetes care for parts of North East Essex, where the number of patients provided with the eight key elements of good diabetes care has risen from 40 per cent to 67 per cent.
But he added that some clinical indicators could take four to five years to show results – a point echoed by other people on the panel. At the same time there was a need for radical change in primary care with an emphasis on consistency, which could help with recruitment and career progress for GPs.
He said: “General practice is drowning. We need to look at how we segment our work instead of piling it in.”
One area that is making far-reaching changes is Croydon. From October, all elderly health and social care will be delivered through an accountable provider, with the potential to expand this to other age groups.
Croydon Health Services Trust chair Mike Bell admitted progress had been helped by having coterminous provision and commissioning with a history of local organisations working together.
“We have a clear vision that is shared by the co-commissioners, the CCG and the local authority,” he said. There was also agreement on what “good” looked like.
However, there were areas where they were less ready – for example, around unpicking the complexities of governance between different organisations.
Mr Bell said: “We have not yet bottomed out all the financial risks and how they sit between the commissioner and provider. We probably have a working model that is sufficient for October, but bearing in mind what happened at Peterborough and Cambridgeshire [where an older people’s services contracts was handed back to the commissioners] that is a big risk.
”The confidence for the future is that we are all committed to making it work.”
General practice is drowning. We need to look at how we segment our work instead of piling it in
National primary and acute care system lead for the vanguards Jacob West said the NHS England team was trying to draw out the recurring themes from the different models, such as the right size, engagement and the use of technology.
Mr West said: “I don’t think there is a single way of doing things, but there probably isn’t 150.”
He added that some areas were looking at risk share, others using a prime contractor or prime provider models. He echoed the concerns of many around the table about the speed of delivery of savings, pointing out in Germany when new models were adopted they had not broken even or shown outcomes improvement until year four.
There were also questions about spread and wider adoption and how the learning from the models could be disseminated.
All of this work is taking place against a backdrop of overspending acute trusts, limited budgets and continuing demands for efficiency savings. Mr McLellan raised the question of how much could be achieved within this environment, where additional money was limited, and what couldn’t be delivered.
Mr Bell said he was working within a health economy heading for a massive deficit by 2020-21. “Do we think the ACO can close all the gap?” he asked. “No,” was his reply.
He added there were differences in how quickly partners thought cost savings could be delivered with the hospital trust expecting longer term delivery.
‘We need support from the centre on this, and I don’t think we always get that from the regulators. In a closed health system such as Croydon, you could play swap the deficit for years,” he said.
Holding back change
Dr Kingsland emphasised how much could be done in line with the Carter review including workforce planning, the use of temporary staff and managing assets. The PCH model envisaged efficiency savings of 3 per cent to 5 per cent.
Capacity to tackle many of these areas and release savings may be a challenge in some areas. Mr Streat said there were many smaller projects that would deliver modest savings but not all could be addressed as commissioners did not have time and capacity.
The political situation may also be holding back changes. Mr Evans said: “We can’t do anything until after the referendum. We have public consultation on a lot of this and it is unlikely we will see major changes this year.”
Vanguards have, of course, had some additional funding to help them get going, which Ms Flowers said had helped them move more quickly.
One of the challenges for the wider system is how we get the balance right between money for today and money for transformation for tomorrow
In terms of realising benefits, she said reduced admissions showed benefits quickly but it was harder to show those from reducing staff ‘churn’ in care homes or making them feel more valued.
The pressing financial situation of the NHS is also beginning to have an impact. Mr Martin said: “It does feel like the here and now is beginning to trump the longer term. How can you keep the faith?’
Mr West added there were probably ways in which things could be made easier for vanguards. Longer term funding might help them make better planning decisions and cover some double running costs.
“One of the challenges for the wider system is how we get the balance right between money for today and money for transformation for tomorrow,” he said. The lessons from vanguards might help make the barriers to change lower.
However, he felt there were “green shoots” showing some success from vanguards, which could lead to cost savings. Some panellists felt the issues around money were more complex than just not having enough of it.
Mr Bell said: “We did not manage transformation in the 2000s when there was lots of money. We had the money to implement it and double run, and we didn’t do it. Money is not the block to transformation.”
Cold, hard figures
One key factor in delivering change could be good working relations with partners but this may require a change in mindset after many years when managers have been used to different priorities.
Mr Bell said: “We have created organisations to compete rather than cooperate. We are asking them now to forget everything they have learnt over the past 15 years.”
And, to have the greatest impact, vanguards and new care models will need to influence other regions – which may be through them adopting a model or at least sharing learning.
Ms Flowers felt there was much in the Hertfordshire work that could be used in other areas. The medicines management work in particular was replicable and could pay for itself quickly.
“Sometimes it is showing people the cold, hard figures,” she said.
Roundtable: Who’s who
- Alastair McLellan, editor HSJ (roundtable chair)
- Paul Streat, development director Better Local Care, Southern Health
- Dr Paul Driscoll, chair Suffolk GP Federation
- Andrew Willetts, healthcare solutions director, Celesio UK
- Jamal Butt, head of healthcare solutions, LloydsPharmacy Healthcare Solutions, Celesio UK
- David Evans, chief executive Northumbria Healthcare Trust
- Beverley Flowers, chief executive East and North Hertfordshire CCG
- James Kingsland, president National Association of Primary Care
- Jacob West, NHS England lead on primary and acute care systems
- Mike Bell, chair Croydon Health Services Trust
- Jeremy Martin, director Symphony project in Somerset