NHS vanguards: redesigning the aeroplane in flight

Last month, the 50 vanguard sites in the New Care Models programme met for a series of events in London to take stock of progress. The majority of the sites – those announced in March 2015 – have now been running for 200 days.

As at previous meetings, the enthusiasm was palpable – this is a group of people who believe their projects can make a difference – but so was the weight of expectation. The intention is for the vanguards to make a major contribution to addressing the NHS’s financial challenges – both through improvements in their local systems and blueprints that can be adopted across the rest of the NHS and social care.

As others have argued, the vanguards face the challenge of ‘redesigning the aeroplane in flight’ – making significant changes to the configuration of local health and care systems, all the while sustaining existing services in a difficult environment, with limited spare cash and growing service pressures.

In his first engagements as an international visiting fellow at The King’s Fund, Don Berwick argued emphatically that this can be done. There are now many examples of local health systems that have transformed the quality of care for their populations, while at the same time working with reduced funding. Last month, the Fund published a detailed report about one of Don’s examples, Southcentral Foundation in Alaska, which moved from four-week waits to same-day appointments in primary care, halved A&E attendance, and dramatically reduced hospital referrals and admissions, while coping with declining funding and fewer doctors and nurses per head of population.

As the vanguards know, improvement of this order of magnitude can only come from far-reaching redesign of local health and care systems. We are looking to the vanguards to develop radically different models of care rather than to make incremental improvements within existing systems. Both Don and Mark Smith (founding chief executive officer of the California Healthcare Foundation) challenged the vanguards to shift the balance of power within their health systems (for example, by asking ‘what matters to service users’ rather than ‘what’s the matter with them’). They encouraged the vanguards to come up with the most innovative and disruptive changes, for example, in the roles of doctors, nurses, patients and carers, the use of technology and where care is delivered.

Many researchers on innovation argue that there are fundamental differences between this type of transformative change and more incremental service improvement. Transformative change is typically led from the top and driven by dedicated project teams, with high levels of engagement with staff and communities to win their support and bring their energy and expertise into the projects. Meanwhile, incremental improvement can, and probably should, be led by frontline teams, drawing on support and expertise from elsewhere when needed (see Chris Trimble’s and Vijay Govindarajan’s research among others).

As we know from Southcentral Foundation and other examples, successful transformation also hinges on having clear objectives, transparent measures and a robust methodology to underpin the improvement effort. As Don Berwick puts it, we need both aim and method. Many of the vanguards have now made considerable progress in defining shared objectives and putting in place dedicated project teams, and are starting to define metrics to measure progress.

If the research is correct, the leaders of local NHS systems face a difficult dilemma: whether to focus their limited resources on supporting the vanguards and similar transformation programmes or to spend their time addressing more immediate financial and operational challenges. One message from last month’s discussions is that senior local leaders need to put transformation on the top of their personal ‘to do’ lists, as the long-term solution to those more immediate operational pressures. The national bodies may need to create a more propitious environment – for example, one where regulatory compliance plays a lesser role – for this to happen.

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#545226 Harry Longman
Chief Executive
GP Access Ltd

Well, yes, but we've been helping individual and groups of practices to achieve order of magnitude improvements in service (eg 10 days down to 1 day time to see GP) without a big upheaval in structure and at very low cost. The secret is demand led thinking, and creating capacity by shifting channel from all face to face to telephone and online led. This is well established and proven. 50 examples: http://gpaccess.uk/evidence/the-dover-chart-collection/ Why overegg what is a simple transformation?

#545230 Gordon Cairns
Patient andPublic Voice representative
No organisation now

The whole idea of the Vanguards being a way of getting Patient Involvement at all levels is a misconception as I know . I worked as a volunteer Patient Leader for a MCP Vanguard and was involved with NHS England in Judging the ACC Vanguards and interviews for Vanguard Clinical Associates for the New Models of Care Team .I have found that NHS England have a good Patient Involvement Record but when you get back to the CCG Level it is almost non existent and I have now resigned from the CCG for lack of involvement by Patients at a high enough level . This was at a level where we were just ticking boxes on Business Plans with no inputs to the actual plans and no way to change them . The five year forward view mentions Patient Involvement to the highest level . I have said that CCG Managers and Directors are not patient facing as they are mostly Office Bound and a lot were with PCT's before the CCG 's came out . They have always done to patients not with Patients and a massive change in Culture is needed to bring the type of Patient Involvement that is needed to put Patients at the centre of the Vanguard Project . I am a 69 year old Prostate Cancer survivor for 11 years and know what is going on .

#545234 mike tremblay
policy advisor
cassis ltd

Don Berwick is right to say this can be done. It is a silly way of describing vanguards as trying to reform the aeroplane while in flight. Is there any other way to drive change through a system? Goodness, people in the NHS seem to have a limitless supply of excuses to avoid doing what needs doing. Your dilemma (innovation versus immediate financial pressures) is a false one as a consequence as they collapse with the shift in the balance of power. The NHS 'system' destablises itself because shifting the balance of power breaks the collective logic that hampers innovation.

#545235 Jon

I agree with Mike that every system is having to develop and redesign in flight. Why do you Ben present it as if it's something amazing? What would be amazing is to start looking at the basics as we see time and again on the news and from my experience. That is the development of the NHS which holds as paramount it's relationship with patients and families. The more Ben you talk about systems, vanguards etc you lose the fundamental of human relationships that really define good health and for that matter social care. One other thing is transformational change really possible in the NHS isn't the nature of it reliant on incremental change to make a real difference? W
Ben will you be responding to the comments on here in terms of public engagement?

#545236 GeorgeCoxon

I'm absolutely not going to be negative about ambition, the chosen 50, more gatherings of those chosen to listen (dare I surmise too passively) to one another as they share experiences, progress and impact (my fear is all to slowly).
We are just not being brave enough. Creative enough. Urgent enough. I'm an ex salaried senior NHS clinician, manager, commissioner and know the word 'salaried' sadly creates a culture of 'go slow', risk aversion and most tragic of all a combination of 'what's in it for me' and or otectionism.
We, in the independent sector, who rely on energy, dynamism and 'can do' not 'yes but' don't have the luxury of reliable salaries to look forward to month in month out generally regardless of whether the last conference we attended or even presented at changed anything or not. We have to deliver, to lead, to be credible, to really live the life of making sure what we do works and makes a difference to people needing care, support and treatment or we are quickly out of business and soon forgotten! Really our sustainability is entirely based on delivery and reputation for that delivery. As I say I'm not going to be negative Just frustrated at the same time as determined and proud about how much independent involvement can contribute to true Vanguard and BCF health and social care innovation

#545243 Tim Lund

Tha analogy should be more like a Formula One Team improving their car mid season - but Services are starting from different points and some need radical change!

#545244 john

It starts with the name. Vanguard. Then the #futureNHS hashtag. Or the battering ram of the change. Or redesigning the aeroplane mid flight.
It could easily be Pioneer or a Devolution pilot.

It's like a Monty Python sketch.

The NHS can't book patients in date order..

#545245 Mike Leaf
Director of Health Improvement

The whole of the public sector struggles with the involvement of citizen involvement, some more than others. The NHS seems to find patient involvement difficult, but there are opportunities for working with local government in this regard. Whilst there is variation, public sector employment makes up a significant proportion of the local workforce; many are patients; many family members are patients; and they all know people who have experience of local NHS services. What opportunities are there for a coordinated approach to seeking views from people who use our services? Let us use the assets we have at our disposal

#545249 Kate Brookman
Speciality Integration CNS
Symphony Vanguard project, South Somerset.

Comment from the coalface not the airfield..Whilst not yet at 'Cruising height', this Vanguard project is making rapid and bold changes, after having looked at different successful models of Integrated care in US earlier in project design.We have unashamedly borrowed all the good stuff evidenced (whilst being thankful to only have one "Payer"- the NHS and not multiple Insurers) and are bringing in Metrics already-first signs look very promising .We need Vanguard sites to deliver enthuisiasm tempered with cold economics and to make those Trusts not involved , feel included, not sidelined in the journey being taken.

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