Increased demand for care won't be addressed by doing more of the same

With the first anniversary of the NHS five year forward view approaching rapidly, how are new care models developing, and what are the prospects for the future?

Even at this early stage, it is clear that the new care models programme has unleashed a good deal of energy and welcome variety in the approaches adopted. Five types of vanguard are now in development, encompassing multispecialty community providers (MCPs), primary and acute care systems (PACS), enhanced health in care homes, urgent and emergency vanguards, and acute care collaborations. It is encouraging too that the programme is sponsored by seven national bodies who are working together to support innovations in care.

While it is far too soon to assess the impact of the vanguards, it is clear that they face some common challenges. These include creating time to implement new care models when the NHS is faced with growing financial and operational pressures, and extending involvement from a small number of enthusiastic champions to frontline staff and others who will be critical in ensuring that patients really do experience improvements in care. Another challenge is overcoming legislative and regulatory barriers to collaborative working.

The history of pilot programmes in the NHS demonstrates the need to allow time for the vanguards to demonstrate results and to avoid a rush to judgement. It also points to the need for dedicated programme management support as plans move from the drawing board into practice. With most of the vanguards seeking to achieve closer integration of care, it is particularly important that there is deep and genuine engagement by doctors, nurses and other staff since evidence shows that clinical integration rather than organisational integration is what delivers benefits.

One of the biggest risks facing the programme is that dealing with financial and operational pressures will crowd out the time needed to design and implement new care models. The trick here is to see the models as part of the solution to these pressures rather than an unhelpful distraction. Dealing with rising demand for hospital care cannot be achieved through ‘more of the same’ and the work being done in many of the vanguards to tackle avoidable hospital admissions through better co-ordinated care holds out the hope that ‘doing things differently’ will be more effective.

Our work at the Fund on high-performing health care systems has shown that improving the delivery of care involves a long march in which benefits result from ‘the aggregation of marginal gains’ rather than a major breakthrough. These gains occur when frontline staff are supported to improve care and have the space to do so. The challenge for national and organisational leaders is to protect the time of key staff involved in the vanguards and to provide the support they need to put in place sustainable solutions.

Our work has described the journey from fragmented care to integrated care and on to population health as the path that needs to be followed in implementing the Forward View. Devo Manc is an ambitious example of an attempt to do this by improving health and wellbeing through action across a range of services and sectors. Population health improvement is the prize on offer where NHS organisations and their partners can find common cause in working together to deal with the unprecedented challenges facing public services in this parliament.

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Comments

#544932 Mike Smith
Chairman
Patients Association

This blog is like a breath of fresh air. `More of the same' cannot be the way forward to overcome the lack of 24/7 integrated care that we all need and deserve. Local leadership seems to be the way that some of the local difficulties can be overcome and, with good fortune and dissemination of the improvements in health and well-being of not just patients but staff too, we might at last begin the beat the current resistance to such integration everywhere.

#544936 Craig Wakeham
GP
Dorset CCG

Chris is of course right, the problem is we do know this and have done for some time. The system seems to be set-up to prevent us achieving the required and necessary transformation. Productivity and Quality need to be harnessed as a team to pull the chariot rather than be the conflicting agendas/processes they seem to always be. All the knowledge tells us this is what works but the practical application all to often creates the conflict that prevents the realisation.

#544942 David Oliver
Consultant Physician
Royal Berkshire Hospital

I agree with all Chris says here and declare my interest as a King's Fund fellow and someone who has given advice here and there to new models/future hospitals and acute trust under urgent care pressure.

However, without being an "austerity denier" unaware of the national political context i have a bigger contextual question. "Why do we assume that the increased demand for care is necessarily inappropriate, that preventing it is necessarily desireable or equates with "better care" or the a funding gap is inevitable.

Not everyone likes the commonwealth fund reports but George Osborne Cited them in the Spending Review document as evidence of an already efficient, value for money NHS. The Economist Intelligence Unit compared the UK with a wider range of nations and also found that we were comparably underfunded, efficient and had fairly few staff beds and equipment. England has the lowest acute beds/1000 in the OECD or something close to that. Hospitals run very close to full ocucpancy. In terms of doctors per head of population we are not high up the tables of developed natios and we have major workforce crises in nursing, general practice and some acute specialities. We have slashed social care funding by c 40% in the past 5 years or so which has drastically impacted on provision to support individuals and in turn on the NHS.

Against this background, urgent demand has risen despite the contracting acute bed base and rising delayed transfers of care. Yet we still manage to see and treat most patients of all triage levels within 4 hours (unheard of and undelivered in most other systems) - yet we call it some kind of national scandal when even 1 in 10 people cant be seen in those 4 hours.
Shouldnt we reframe this to point out that our A&E departments are exemplary and efficient and providing such a good responsive service to the public that they are being used in record numbers?

Meanwhile General Practice activity has increased dramatically against progressively reduced funding in terms of % of whole NHS spend and despite a major GP recruitment and replacement crisis mirrored in district nursing

Perhaps we should invest more in prevention and wellbeing? Yet the government ahs cut public health budgets by c £250m and has been slow to move from "nudge" and embrace policies on salt, sugar, food labelling, transfats, alchohol pricing etc due to its relationship with lobbyists rather than committment to evidence based practice

So maybe in all of this we should re-iterate what the Barker Commission and other kings fund publications have suggested - we could make the political choice to fund and staff properly a service that is already running very hot and pretty efficiently compared to most systems

I might go further and suggest that there is a whole apparatus caused by the English Internal Market (and not seen in Scotland) and multiplicitiy of national bodies and regulators that could usefully be swept away to allow local service leaders to get on with their jobs free of so much top down pressure

Finally, whislt we can never depoliticise a state funded national health service it would be good (as Simon Stevens was effectively saying in the five year forward view) to allow the system some stability and allow new models to bed down, have a chance to work and allow adequate improvement support to help others adopt the successful ones.

A cycle of change whose pace relies on elections and ministerial reshuffles cannot allow this stability so i would prefer politiicans to

1. Fund the service properly
2. Ensure adequate workforce training and provision
3. Do all it can not to demoralise the worfkorce and cause further issues (e.g. Mr Hunt's pronouncements regarding GPs, Doctors contracts etc)
4. Be honest with the public about what can and can't be delivered or expected (for instance promising full 7 day services with no additional workforce or funding) and the fact that performance will inevitably drop off (as it has in statutory social service provision) if funding and staffing are inadequate

David Oliver

#544943 Fiona Flaherty
Independent Public Health Nurse Consultant
Meducate Healthcare Ltd

Building a sustainable public health future requires more than just sticky plaster and empty promises.

The one thing we don't have is endless time. If you want it to happen then it requires a massive 'buy-in' from the population/public at large.

Tower HamletsBorough in east London, UK recently commissioned (through the transparency of a Community Intelligence Bursary) the views of the public on current services and needs. A tad under 1,200 individuals told their personal stories. The findings highlighted a single thread, and it was this.

If you ask the population what is important to them they will offer practical solutions based on collaboration between the providers, the third sector and those who will use the services. A win-win for all.

Surprisingly, many of the recommendations were around reworking and remodelling current services and systems, and not about 'new'.

I was involved as a Community Researcher in this project and was excited by the endless possibilities it brought to light. This Borough is certainly one to watch.

If you want effective change, as Chris Ham has eluded to earlier, you need to ask the customers/clients/patients what they want and how they want it delivered. After all, we are all accessing, using and leaving services at differing times and therefore 'one hat' will never fit us all!

Change is always a moveable force and there will always be winners and losers. But the time has come to deliver services that are wholly relevant. For in the long run, it will be the most logical path to follow..

#544944 Kerry Bareham
Clinical Team Lead Complex Case Manager
Lincolnshire Community Health Services

With you all the way.

In Primary Care we continue to have a system driven by QoF which has the unintended consequence of over medicating and failing to assess for and subsequently meet the needs of older people with frailty. Instead we have an NHS built on the medical model of cure and discharge. While the professionals working inside it may recognise this, poor commissioning and short sighted goal and Government interference creates unnecessary barriers.

While in my own area of practice I am slowly beginning to garner recognition that age and frailty are not predictors of each other, and a social gerontological approach is required. This is on top of the day job, that has seen District Nursing caseloads more than double over the past 5 years with increased complexity.

We have the answers but we need the time and resource to bed them in as you say. Front line clinicians also need to be trusted. Unfortunately in my area of practice because the demand is so great the bean counting that would support the evidence needed is sacrificed in order to ensure patient care is prioritised. This leads to scewed data that our corporate side appears to hold more store by, than the voice and research of experienced clinicians.

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