Vanguard ups and downs: A local perspective

The new care models programme has felt like a genuinely different national approach to transformation. When we first applied to be a vanguard site, we were not convinced that any of the models described in the NHS Five Year Forward View really fitted with what we needed to do on the Isle of Wight. But thankfully, the programme recognised early on that one size does not fit all.

The approach taken by the national team has not been a “Big Brother” approach but rather a supportive one in which we have been encouraged to push the boundaries and develop our own model of care, within the loose framework provided by the primary and acute care system model.

The model recommends a set of components that experience has shown provide a good model of care, but it also recognises that local systems can and will implement these components in different ways based on their existing provision and population needs.

Being a vanguard site gave us an opportunity to increase our local capacity and capabilities so that we could transform our services at a greater pace

Perhaps, the most significant benefit from being part of the programme has been the opportunity to learn from others and share experiences – including insights into what has not worked well and how people might have approached things differently in retrospect. The national team organised some very useful learning events where vanguard sites came together to discuss our experiences and to share progress and ideas.

Being a vanguard site also gave us an opportunity to increase our local capacity and capabilities so that we could transform our services at a greater pace. It enabled us to benefit from specific expertise, with support from specialists in evaluation, logic modelling, information governance and other issues.

Challenges

There have, of course, also been challenges. Vanguard sites have been required to undertake a substantial amount of reporting. Efforts were made throughout the programme to make reporting requirements as simple as possible, but this was still a large commitment. We also felt the goal posts seemed to move between year zero and year three, with priorities, funding and expectations changing.

Some of the national communication and requirements had the unintended effect of disengaging non-health partners

Although the programme was designed to drive integration across health and social care, some of the national communication and requirements had the unintended effect of disengaging non-health partners. For example, the national indicator sets used to measure success were very health-focused (eg, non-elective admissions or hospital bed days). This sometimes made it harder to engage with our local stakeholders beyond the NHS.

Lessons

In terms of lessons from our experience, the first piece of advice I would offer to other local leaders embarking on this kind of journey is to ensure you focus on key priorities. Keep it simple – avoid taking on too much or having too broad a scope.

It is better to pick off a couple of areas, deliver on them, learn and celebrate, and then move on to the next areas. And as part of this process, it should be remembered that it is OK to not get it right first time. The important thing is to fail fast – to implement, evaluate and adapt where necessary.

My second piece of advice for leaders in other areas is never to underestimate the importance of relationships. Ensure you have the right people involved in each part of the programme, and that there is regular communication with all involved on plans and progress. Keeping the momentum up means maintaining trust and being open and transparent with partners at all times.

There are also some important lessons for those designing future national programmes. There has been, and continues to be, frustration in relation to the legal and technical barriers to introducing new care models – for example around VAT, pensions, contractual terms and conditions, information governance and procurement laws.

There has been, and continues to be, frustration in relation to the legal and technical barriers to introducing new care models

More consideration and support needs to be given to these issues, so that they are tackled once at a national level rather than each area having to work things through independently and finding local fixes or workarounds, which are often less than ideal.

Related to this, national partners need to identify where real practical support can be procured at scale, for example, specialist support in organisational development that could be offered to local areas or legal advice to support national contract changes.

In recent years, there have been a large number of national programmes intended to support local transformation, and it would be helpful if there was greater alignment between these.

The impact of the new care models programme could have been strengthened if there was more explicit and more practical tie-in to NHS RightCare, Getting It Right First Time, the Carter review on hospital productivity, and the Model Hospital programme.

The goal of national leaders should be to secure alignment between these and other programmes, in order to maximise the benefit for local systems and minimise the effort.

It would also be helpful if there was a clearer national focus on prevention. Keeping people healthy and reducing avoidable NHS activity are critical parts of all new care models. Local efforts to do this need to be backed up by more investment at the national level and a firmer national approach towards prevention.  

The Island now has an agreed transformation plan – the Local Care Plan – that sets the vision for the next two years across the health and care system. This single plan for our system has been informed by the PACS framework and builds on the work we have done through the new care models programme. We will continue to work with local partners on and off the Island to implement this shared vision.

Nicola Longson was programme director for My Life a Full Life (the Isle of Wight primary and acute care system vanguard) in 2016. Before this, she was assistant chief transformation officer for North Derbyshire Clinical Commissioning Group.

This article is part of a King’s Fund report published today, Developing new models of care in the PACS vanguards.